B25.9

HCC Category Mapping

What This Code Means

A viral infection caused by cytomegalovirus (CMV) where the specific affected body part or system is not documented or identified.

Coding Tips

• •Use this code only when the documentation does not specify which organ system is affected by CMV; if a specific site is documented, use a more specific B25 code
• •Common in immunocompromised patients; review clinical context to determine if a more specific code applies

Clinical Significance

Cytomegaloviral disease, unspecified, is used when CMV infection is documented but the specific organ system affected is not identified. This code should prompt a query to the provider for site specification, as the clinical management and documentation quality improve with site-specific coding.

Documentation Requirements

• ✓Confirmed CMV infection (positive CMV PCR, culture, or antigen test)
• ✓Documentation that a specific organ involvement could not be determined
• ✓Clinical context: symptoms, immunocompromised status
• ✓Plans for further diagnostic workup to identify the affected organ system
• ✓Treatment regimen documented (empiric antiviral therapy)

Commonly Confused Codes