Secondary syphilitic nephritis is a renal complication arising from secondary syphilis, characterized by inflammation of the kidneys due to the systemic spread of Treponema pallidum. This condition is clinically significant as it can lead to renal impairment and requires accurate coding with ICD-10 Code A51.44 for proper diagnosis, documentation, billing, and public health reporting.
What is ICD-10 Code A51.44 for Secondary syphilitic nephritis?
ICD-10 Code A51.44 represents Secondary syphilitic nephritis, a renal manifestation of secondary syphilis. This code should be used when documenting cases where nephritis is directly linked to the underlying syphilitic infection, ensuring appropriate clinical documentation and billing for treatment and management.
ICD-10 Code A51.44 – Clinical Definition and Explanation of Secondary syphilitic nephritis
Secondary syphilitic nephritis is caused by the dissemination of Treponema pallidum, leading to kidney inflammation. It is crucial for clinicians to recognize this condition due to its potential for serious renal complications, necessitating prompt medical intervention.
Key Clinical Features:
- Hematuria (blood in urine)
- Proteinuria (excess protein in urine)
- Edema (swelling due to fluid retention)
- Hypertension (high blood pressure)
ICD-10 Code A51.44 for Secondary syphilitic nephritis – SOAP Notes & Clinical Use
In SOAP notes, ICD-10 Code A51.44 is utilized to document the diagnosis of Secondary syphilitic nephritis, aiding in the assessment of symptoms, clinical findings, and treatment plans. This code is relevant in both acute and chronic care settings.
What Does ICD-10 Code A51.44 for Secondary syphilitic nephritis Mean in SOAP Notes?
ICD-10 Code A51.44 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Secondary syphilitic nephritis, ensuring continuity of care and supporting accurate billing and EHR documentation.
Treatment Options for ICD-10 Code A51.44 – Secondary syphilitic nephritis
Secondary syphilitic nephritis requires urgent medical attention, often necessitating hospitalization for effective management.
Antibiotic Therapy:
- Benzathine penicillin G (first-line, single dose)
- Doxycycline (alternative, 100 mg twice daily for 14 days)
- Ceftriaxone (alternative, 1-2 g daily for 10-14 days)
Supportive Care:
- Hydration to maintain renal function
- Monitoring of renal function and electrolytes
- Management of hypertension and edema
Infection Control:
- Standard precautions to prevent transmission
- Patient education on syphilis transmission and treatment adherence
How to Document Symptoms of Secondary syphilitic nephritis (ICD-10 A51.44) in SOAP Notes
Subjective:
- Patient reports hematuria and increased urinary frequency
- Complains of lower back pain and fatigue
- History of secondary syphilis treated previously
Objective:
- Blood pressure 150/90 mmHg
- Urinalysis shows proteinuria and hematuria
- Swelling noted in lower extremities
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SOAP Note Guidelines for Diagnosing Secondary syphilitic nephritis (ICD-10 Code A51.44)
Assessment:
- Diagnosis: Secondary syphilitic nephritis, moderate severity
- ICD-10 Code: A51.44
- Contributing factors: History of untreated syphilis
Plan:
- Initiate benzathine penicillin G treatment
- Educate patient on syphilis and renal health
- Schedule follow-up in one week to monitor renal function
Treatment & Plan Section for ICD-10 Code A51.44 – Secondary syphilitic nephritis
- Administer appropriate antibiotic therapy based on sensitivity
- Implement lifestyle modifications to support renal health
- Monitor renal function through regular lab tests
- Educate patient on signs of worsening renal function
Using ICD-10 Code A51.44 for Secondary syphilitic nephritis in Billing & SOAP Note Compliance
- Ensure accurate documentation of symptoms and clinical findings in SOAP notes
- Use A51.44 in conjunction with relevant CPT codes for billing
- Align treatment plans with clinical guidelines to justify billing
- Document patient education and follow-up plans clearly
Related ICD-10 Codes Often Used with Secondary syphilitic nephritis
- A51.0 – Primary syphilis
- A51.1 – Secondary syphilis
- N00.9 – Acute nephritis, unspecified
- N01.9 – Nephritis, unspecified
ICD-10 Code A51.44 in Medical Billing and Insurance for Secondary syphilitic nephritis
ICD-10 Code A51.44 is essential for accurate billing in hospital, ER, or infectious disease care settings.
Billing Notes:
- Document all relevant clinical findings to support the diagnosis
- Use A51.44 in the context of renal complications for accurate coding
- Ensure compliance with payer requirements for documentation
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 99223 | Initial hospital care, typically 70 minutes or more of total time on the date of the encounter |
| 81002 | Urinalysis, automated, with microscopy |
| 96372 | Therapeutic, prophylactic, or diagnostic injection |
Frequently Asked Questions
Common Questions About Using ICD-10 Code A51.44 for Secondary syphilitic nephritis
What are the common symptoms of Secondary syphilitic nephritis?
Common symptoms include hematuria, proteinuria, lower back pain, and edema. Patients may also experience fatigue and hypertension as the condition progresses.
How is Secondary syphilitic nephritis treated?
Treatment typically involves antibiotic therapy, primarily benzathine penicillin G, along with supportive care to manage symptoms and monitor renal function.
When should ICD-10 Code A51.44 be used?
ICD-10 Code A51.44 should be used when documenting cases of nephritis that are directly related to secondary syphilis, ensuring accurate diagnosis and billing.
Is hospitalization required for Secondary syphilitic nephritis?
Hospitalization may be necessary for patients with severe symptoms or complications, particularly if renal function is significantly impaired.
