2025 ICD-10-CM code A04.72
(Active) Effective Date: N/A Certain infectious and parasitic diseases - Intestinal infectious diseases A00-B99 Feed
Enterocolitis due to Clostridium difficile, not specified as recurrent.
Medical necessity is established by the presence of signs and symptoms consistent with C. diff infection, confirmed by laboratory testing.The severity of symptoms, potential complications, and treatment plan should be documented.
The physician is responsible for diagnosing C. diff enterocolitis based on symptoms, history, physical exam, and lab tests. Treatment involves discontinuing causative antibiotics (if feasible), rehydration, probiotics, and targeted antibiotic therapy (metronidazole or vancomycin).For recurrent cases, fecal microbiota transplantation or other antibiotics may be considered.Surgical intervention may be necessary for complications like colon perforation.
In simple words: This code represents an infection of the intestines caused by the C. diff bacteria, resulting in inflammation. It's often associated with antibiotic use and doesn't specify if the infection has happened before.
Enterocolitis due to Clostridium difficile, not specified as recurrent. This code indicates inflammation of both the small intestine and the colon caused by the bacterium Clostridium difficile, without specifying whether it is a repeat occurrence.
Example 1: A patient presents with watery diarrhea, abdominal cramps, and fever after a course of antibiotics. Lab tests confirm C. diff infection., An elderly patient in a long-term care facility develops severe diarrhea and dehydration.C. diff is identified as the causative agent., A patient with a history of C. diff infection experiences a new episode of diarrhea.While it is suspected to be a recurrence, further investigation is needed.
Documentation should include symptoms (diarrhea, abdominal pain, fever), history of antibiotic use, laboratory results confirming C. diff, and any procedures performed (e.g., colonoscopy, sigmoidoscopy).For recurrent cases, clearly document the number and dates of prior infections.
- Specialties:Gastroenterology, Infectious Disease, Internal Medicine, Family Medicine, Geriatrics
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office, Nursing Facility, Skilled Nursing Facility