Clostridioides difficile Infection Documentation Guide
Toxin-mediated colitis caused by Clostridioides difficile, typically following antibiotic exposure.
ICD-10 Codes: A04.71, A04.72
Common Symptoms
- Watery diarrhea
- Abdominal cramping
- Fever
- Leukocytosis
- Hypoalbuminemia
Key Documentation Elements
- Episode classification (initial, first recurrence, multiple recurrences)
- Severity (WBC >15K, Cr >1.5, hypotension, ileus, megacolon)
- Testing method (PCR, toxin EIA, GDH)
- Treatment regimen (vancomycin, fidaxomicin, bezlotoxumab)
- Antibiotic stewardship and recurrence prevention plan
Documentation Challenges
- Documenting initial vs recurrent episode classification
- Recording severity assessment (non-severe, severe, fulminant)
- Capturing antibiotic exposure history and de-escalation
- Tracking treatment response and recurrence prevention
Billing Considerations
- A04.71 (enterocolitis) vs A04.72 (colitis) distinction
- Recurrent infection documentation for advanced therapy authorization
- Isolation and infection control documentation
Frequently Asked Questions
What distinguishes A04.71 from A04.72?
A04.71 is C. difficile enterocolitis (small and large bowel involvement), while A04.72 is C. difficile colitis (large bowel only). Scribeable codes based on your documented clinical presentation and imaging.
How does Scribeable document C. diff management?
Scribeable captures severity markers, treatment regimen, recurrence history, and antibiotic stewardship decisions from your encounter, supporting proper classification and advanced therapy authorization.