Find information on H. pylori positive diagnosis, including clinical documentation, medical coding (ICD-10 code K25.5), and healthcare guidelines. Learn about H. pylori infection, treatment, and management for accurate medical records and billing. Explore resources for healthcare professionals regarding H. pylori tests, diagnosis confirmation, and appropriate medical terminology. This resource provides insights into H. pylori positive gastritis, ulcers, and other related conditions for accurate clinical documentation and coding practices.
Also known as
Other bacterial agents as the cause
H. pylori infection is classified under bacterial agents.
Diseases of esophagus, stomach and duodenum
H. pylori can cause conditions like gastritis and ulcers.
Symptoms and signs involving the abdomen and pelvis
H. pylori infections can present with abdominal pain or discomfort.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is H. pylori infection active?
Yes
Duodenal ulcer present?
No
History of H. pylori?
When to use each related code
| Description |
|---|
| H. pylori Positive |
| Gastritis, H. pylori related |
| Duodenal ulcer, H. pylori+ |
Coding lacks specificity (e.g., location, active/inactive). Impacts reimbursement and quality reporting. CDI review needed.
Diagnosis based on symptoms only, lacking lab confirmation. Causes inaccurate reporting and potential overtreatment. Audit target.
Coding active H. pylori after successful treatment. Leads to inflated prevalence rates and unnecessary follow-up. Requires CDI query.
Patient presents with symptoms suggestive of Helicobacter pylori infection, including epigastric pain, dyspepsia, bloating, and nausea. The patient reports intermittent burning sensation in the upper abdomen, relieved temporarily by antacids. Physical examination reveals mild tenderness to palpation in the epigastric region. No rebound tenderness or guarding noted. Differential diagnoses considered include peptic ulcer disease, gastritis, and non-ulcer dyspepsia. To confirm the diagnosis of H. pylori, a urea breath test was performed, yielding a positive result. This confirms active H. pylori infection. Stool antigen test was also considered, but the urea breath test was chosen for its higher sensitivity in detecting active infection. Serology for H. pylori antibodies was deemed less relevant in this case due to its inability to differentiate between current and past infection. The patient will be started on triple therapy, which includes a proton pump inhibitor (PPI), clarithromycin, and amoxicillin, for H. pylori eradication. Risks and benefits of treatment, including potential side effects such as diarrhea and antibiotic resistance, were discussed with the patient. Patient education provided regarding medication compliance, lifestyle modifications such as dietary adjustments, and follow-up testing to confirm eradication of H. pylori. ICD-10 code K21.0 (Acute gastritis caused by Helicobacter pylori) is assigned. Medical billing codes for the urea breath test and prescribed medications will also be applied. Follow-up scheduled in four weeks to reassess symptoms and to discuss potential need for a repeat urea breath test or stool antigen test to confirm eradication.