Find comprehensive information on diagnosing a history of Clostridium difficile infection. This resource covers clinical documentation requirements, medical coding guidelines for CDI, and healthcare best practices for identifying prior C. diff infections. Learn about diagnostic criteria, including stool test results, PCR testing, and toxin assays. Explore accurate coding using ICD-10-CM codes for recurrent CDI and past C. diff colitis. Improve your clinical documentation for a history of C. difficile infection to ensure proper coding and reimbursement.
Also known as
Enterocolitis due to C. difficile
This code specifies a past episode of C. difficile infection.
Other specified noninfective gastroenteritis and colitis
May be used for post-infectious complications if no specific code exists.
Personal history of infectious and parasitic diseases
Indicates a past history of C. difficile or other infections.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the C. difficile infection currently active?
Yes
Do NOT code as history of. Code the active C. difficile infection (e.g., A04.7)
No
Any documented complications from prior CDI?
When to use each related code
| Description |
|---|
| Clostridium difficile Infection |
| Antibiotic-associated diarrhea |
| Inflammatory bowel disease |
Lack of documentation clarity to differentiate between active CDI, history of CDI, or colonization, leading to inaccurate coding (e.g., B96.81 vs. Z86.11).
Coding CDI without specifying if it was hospital-acquired or community-acquired impacting reimbursement and quality metrics (e.g., A04.7).
Failing to capture history of CDI in coding impacting patient risk stratification and future care planning (e.g., Z86.11).
Patient presents with a history of Clostridium difficile infection (CDI), also known as Clostridioides difficile colitis. Previous episodes of C. difficile diarrhea were documented on [date(s) of previous CDI]. The patient reports [current symptoms, e.g., abdominal pain, cramping, watery diarrhea, fever, nausea]. Frequency of bowel movements is approximately [number] per day. Stool consistency is described as [description, e.g., loose, watery, bloody]. Onset of current symptoms began [duration] ago. Past medical history includes [relevant comorbidities, e.g., inflammatory bowel disease, recent antibiotic use, hospitalization, immunosuppression]. Prior CDI treatment included [medications and duration, e.g., oral metronidazole, oral vancomycin, fidaxomicin]. Physical examination reveals [relevant findings, e.g., abdominal tenderness, dehydration, fever]. Differential diagnosis includes infectious colitis, irritable bowel syndrome, and inflammatory bowel disease exacerbation. Diagnostic testing for C. difficile, such as a stool toxin assay or PCR, is planned. Treatment for recurrent Clostridium difficile infection will be determined based on test results and severity of symptoms and may include antibiotic therapy with vancomycin, fidaxomicin, or bezlotoxumab. Supportive care, including fluid and electrolyte management, will be provided as needed. Patient education regarding infection prevention measures, including hand hygiene, will be reinforced. The patient's clinical status will be closely monitored for response to therapy and development of complications such as pseudomembranous colitis, toxic megacolon, or sepsis. ICD-10 code A04.7 will be used for recurrent Clostridium difficile infection.