Find information on oropharyngeal candidiasis diagnosis, including clinical documentation, ICD-10 codes (B37.0), SNOMED CT concepts, and healthcare best practices. Learn about oral thrush symptoms, treatment, and differential diagnosis for accurate medical coding and improved patient care. This resource provides guidance for clinicians on documenting oropharyngeal candidiasis in medical records and understanding associated medical terminology.
Also known as
Candidiasis of mouth
Fungal infection of the mouth caused by Candida species.
Other candidiasis
Candidiasis affecting sites not specifically classified elsewhere.
Candidiasis, unspecified
Candidiasis without further specification of location or type.
Diseases of lips
Includes various lip disorders, sometimes a site of oral candidiasis spread.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the candidiasis confirmed or suspected?
Confirmed
Pseudomembranous?
Suspected
Code B37.9
When to use each related code
Description |
---|
Oral thrush |
Leukoplakia |
Oral lichen planus |
Coding B37.9 (Candidiasis, unspecified) when clinical documentation supports oropharyngeal location. Impacts reimbursement and quality metrics.
Failing to code underlying conditions like HIV or diabetes that contribute to oropharyngeal candidiasis. Affects risk adjustment.
Coding for bilateral involvement when only unilateral is documented, or vice versa. Leads to inaccurate clinical data reporting.
Patient presents with complaints consistent with oropharyngeal candidiasis, also known as oral thrush. Symptoms include white patches on the tongue, inner cheeks, and sometimes the roof of the mouth, gums, and tonsils. The patient may report pain, a burning sensation, or difficulty swallowing. Lesions are described as creamy white plaques that can be scraped off, revealing erythematous mucosa. Differential diagnosis includes leukoplakia, hairy leukoplakia, and other oral infections. Diagnosis confirmed via clinical examination and, if necessary, microscopic examination with potassium hydroxide preparation revealing pseudohyphae and yeast cells. Risk factors assessed included recent antibiotic use, corticosteroid use, inhaled corticosteroid use, denture use, diabetes mellitus, immunosuppression, HIV infection, and xerostomia. The patient's current medications were reviewed. Treatment plan includes antifungal medication such as nystatin oral suspension, clotrimazole troches, or fluconazole tablets. Patient education provided regarding proper oral hygiene, medication administration, and follow-up care. ICD-10 code B37.0, Oral Candidiasis, is documented. The patient will be scheduled for a follow-up appointment to assess treatment response and resolution of symptoms. Continued monitoring and management may be necessary for recurrent or persistent infections.