ICD-10 Code A51.45 | Secondary syphilitic hepatitis Symptoms, Diagnosis, Billing

Secondary syphilitic hepatitis is a liver condition resulting from the systemic spread of Treponema pallidum, the bacterium responsible for syphilis. This condition is clinically significant as it can lead to liver dysfunction and complications if not diagnosed and treated promptly. The ICD-10 Code A51.45 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and track this infectious disease.

What is ICD-10 Code A51.45 for Secondary syphilitic hepatitis?

ICD-10 Code A51.45 represents Secondary syphilitic hepatitis, which occurs as a complication of secondary syphilis. This code should be used when documenting cases where liver involvement is evident in patients with a confirmed diagnosis of syphilis. Accurate coding is essential for appropriate clinical documentation and billing, allowing for effective treatment and management of the condition.

ICD-10 Code A51.45 – Clinical Definition and Explanation of Secondary syphilitic hepatitis

Secondary syphilitic hepatitis is caused by the dissemination of Treponema pallidum, leading to inflammation of the liver. It can progress to more severe liver disease if not treated. Prompt medical attention is crucial to prevent complications and manage symptoms effectively.

Key Clinical Features:

• Elevated liver enzymes (AST, ALT) indicating liver inflammation.
• Jaundice due to bilirubin accumulation.
• Fever and malaise as systemic symptoms of syphilis.
• History of syphilis exposure or diagnosis.

ICD-10 Code A51.45 for Secondary syphilitic hepatitis – SOAP Notes & Clinical Use

ICD-10 Code A51.45 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plan for Secondary syphilitic hepatitis. This code is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition.

What Does ICD-10 Code A51.45 for Secondary syphilitic hepatitis Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A51.45 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Secondary syphilitic hepatitis. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code A51.45 – Secondary syphilitic hepatitis

Secondary syphilitic hepatitis requires prompt treatment to prevent liver damage and systemic complications. Hospitalization may be necessary for severe cases.

Antibiotic Therapy:

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

Supportive Care:

• Hydration and electrolyte management.
• Monitoring liver function tests.
• Symptomatic treatment for fever and malaise.

Infection Control:

• Implement standard precautions to prevent transmission.
• Educate patients on safe sexual practices.
• Notify public health authorities as required.

How to Document Symptoms of Secondary syphilitic hepatitis (ICD-10 A51.45) in SOAP Notes

Subjective:

• Patient reports fatigue and malaise.
• History of recent syphilis diagnosis.
• Complaints of jaundice and dark urine.
• No prior liver disease reported.

Objective:

• Elevated AST and ALT levels noted on lab results.
• Physical examination reveals jaundice.
• Temperature of 101°F.
• No abdominal tenderness on palpation.

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SOAP Note Guidelines for Diagnosing Secondary syphilitic hepatitis (ICD-10 Code A51.45)

Assessment:

• Diagnosis: Secondary syphilitic hepatitis, moderate severity.
• ICD-10 Code: A51.45.
• Contributing factors: Recent syphilis infection.
• Monitor for potential liver complications.

Plan:

• Initiate benzathine penicillin G treatment.
• Educate patient on the importance of follow-up.
• Schedule liver function tests in one week.
• Advise on hydration and symptom management.

Treatment & Plan Section for ICD-10 Code A51.45 – Secondary syphilitic hepatitis

• First-line treatment with benzathine penicillin G.
• Consider alternative antibiotics if allergic.
• Monitor liver function tests regularly.
• Educate on lifestyle modifications to support liver health.

Using ICD-10 Code A51.45 for Secondary syphilitic hepatitis in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and history.
• Use A51.45 in conjunction with other relevant codes as needed.
• Align treatment plans with clinical guidelines for billing justification.
• Include detailed notes on patient education and follow-up plans.

Related ICD-10 Codes Often Used with Secondary syphilitic hepatitis

• A51.0 – Primary syphilis
• A51.1 – Secondary syphilis
• B18.2 – Chronic viral hepatitis B
• B18.9 – Viral hepatitis, unspecified

ICD-10 Code A51.45 in Medical Billing and Insurance for Secondary syphilitic hepatitis

ICD-10 Code A51.45 is crucial for billing in hospital, ER, or infectious disease care settings, ensuring proper reimbursement for services rendered.

Billing Notes:

• Document all relevant patient history and symptoms clearly.
• Use A51.45 in the primary diagnosis field for billing.
• Ensure compliance with payer-specific documentation requirements.
• Include detailed treatment plans and follow-up care in notes.

Common CPT Pairings: