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2025 ICD-10-CM code A04.71

Recurrent enterocolitis due to Clostridium difficile.

Use additional code to identify resistance to antimicrobial drugs (Z16.-)

Medical necessity is established by the presence of signs and symptoms consistent with C. diff enterocolitis, laboratory confirmation of the infection, and the recurrent nature of the illness.

Diagnosis involves evaluating symptoms (watery diarrhea, abdominal cramps, fever, fatigue), exposure history, physical exam, and lab tests of feces. Treatment includes discontinuing antibiotics (if possible), rehydration, probiotics, and antibiotics like metronidazole or vancomycin. For recurrences, fecal microbiota transplant or other antibiotics may be used. Surgery may be necessary for complications like colon perforation.

In simple words: Recurring infection and inflammation of the large intestine caused by the Clostridium difficile bacteria, often occurring after antibiotic use.

Enterocolitis due to Clostridium difficile, recurrent

Example 1: A patient presents with multiple episodes of watery diarrhea, abdominal pain, and fever after a course of antibiotics. Lab tests confirm Clostridium difficile infection, and the patient is diagnosed with recurrent C. diff enterocolitis., An elderly patient in a long-term care facility develops severe diarrhea and dehydration following antibiotic treatment. C. difficile is identified in stool samples, and the patient's history reveals previous C. diff infections, indicating recurrent enterocolitis., A patient with a history of C. diff infection experiences another episode of diarrhea and cramping.A colonoscopy reveals pseudomembranous colitis, confirming recurrent C. diff enterocolitis.

Documentation should include symptoms (frequency and characteristics of diarrhea, abdominal pain, fever), history of antibiotic use, laboratory test results confirming C. diff, and details of prior C. diff infections to establish recurrence.If applicable, colonoscopy or sigmoidoscopy findings should also be documented.

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