ICD-10 Code A51.2 | Primary syphilis of other sites Symptoms, Diagnosis, Billing

Primary syphilis of other sites refers to the initial stage of syphilis infection that occurs outside the typical genital or oral areas. It is caused by the bacterium Treponema pallidum and is clinically significant due to its potential to progress to more severe stages if untreated. Accurate coding with ICD-10 Code A51.2 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can track and manage this infectious disease effectively.

What is ICD-10 Code A51.2 for Primary syphilis of other sites?

ICD-10 Code A51.2 represents primary syphilis occurring at sites other than the genital or oral regions. This condition is characterized by the presence of a painless ulcer, known as a chancre, at atypical locations. The code should be used in clinical documentation and billing when a patient presents with symptoms indicative of primary syphilis that do not conform to the more common presentations.

ICD-10 Code A51.2 – Clinical Definition and Explanation of Primary syphilis of other sites

Primary syphilis of other sites is caused by the spirochete Treponema pallidum, which can infect various body areas, leading to the formation of a chancre. This stage is crucial for diagnosis and treatment, as early intervention can prevent progression to secondary and tertiary syphilis. Medical attention is required to manage symptoms and prevent transmission.

Key Clinical Features:

• Presence of a painless ulcer (chancre) at non-genital sites
• Possible lymphadenopathy in regional lymph nodes
• History of potential exposure to syphilis
• Asymptomatic in some cases, complicating diagnosis

ICD-10 Code A51.2 for Primary syphilis of other sites – SOAP Notes & Clinical Use

ICD-10 Code A51.2 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans. It plays a vital role in both acute and chronic care settings, ensuring that the diagnosis is accurately recorded and that appropriate treatment protocols are followed.

What Does ICD-10 Code A51.2 for Primary syphilis of other sites Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A51.2 connects subjective reports of symptoms and objective clinical findings to a formal diagnosis of primary syphilis at atypical sites. This code is essential for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A51.2 – Primary syphilis of other sites

Primary syphilis of other sites requires prompt treatment to prevent complications and transmission. Antibiotic therapy is the cornerstone of management.

Antibiotic Therapy:

• Benzathine penicillin G (2.4 million units IM once)
• Doxycycline (100 mg orally twice daily for 14 days)
• Tetracycline (500 mg orally four times daily for 14 days)

Supportive Care:

• Pain management with analgesics as needed
• Patient education on safe practices and follow-up care
• Monitoring for potential allergic reactions to antibiotics

Infection Control:

• Counseling on safe sexual practices to prevent transmission
• Notification of sexual partners for testing and treatment
• Adherence to local public health guidelines during outbreaks

How to Document Symptoms of Primary syphilis of other sites (ICD-10 A51.2) in SOAP Notes

Subjective:

• Patient reports a painless ulcer on the arm
• History of recent sexual contact with an unknown partner
• No prior history of syphilis or STIs
• Denies fever or systemic symptoms

Objective:

• Ulceration observed on the left forearm, measuring 1 cm
• Regional lymphadenopathy noted in the left axilla
• No signs of secondary syphilis present
• Vital signs stable, no fever

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SOAP Note Guidelines for Diagnosing Primary syphilis of other sites (ICD-10 Code A51.2)

Assessment:

• Diagnosis: Primary syphilis of other sites, A51.2
• Severity: Mild, localized infection
• Contributing factors: Recent sexual exposure
• No evidence of systemic involvement

Plan:

• Initiate treatment with Benzathine penicillin G
• Educate patient on safe sexual practices
• Schedule follow-up appointment in one week to assess treatment response
• Consider serologic testing for syphilis at follow-up

Treatment & Plan Section for ICD-10 Code A51.2 – Primary syphilis of other sites

• First-line treatment with Benzathine penicillin G
• Patient education on the importance of completing the antibiotic course
• Monitoring for treatment efficacy and potential side effects
• Follow-up serologic testing to confirm treatment success

Using ICD-10 Code A51.2 for Primary syphilis of other sites in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings
• Use A51.2 in conjunction with appropriate CPT codes for billing
• Maintain compliance with coding guidelines to support claims
• Document treatment plans clearly to justify billing and follow-up care

Related ICD-10 Codes Often Used with Primary syphilis of other sites

• A50.0 – Congenital syphilis, unspecified
• A51.0 – Primary syphilis of genital organs
• A51.1 – Primary syphilis of oral cavity
• A52.0 – Secondary syphilis
• A53.0 – Late syphilis

ICD-10 Code A51.2 in Medical Billing and Insurance for Primary syphilis of other sites

ICD-10 Code A51.2 is critical in medical billing, particularly in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant patient history and clinical findings thoroughly
• Use A51.2 in the appropriate clinical context to support claims
• Ensure that treatment plans align with documented diagnoses for compliance

Common CPT Pairings: