ICD-10 Code A52.11 | Tabes dorsalis Symptoms, Diagnosis, Billing

Tabes dorsalis is a late manifestation of syphilis characterized by degeneration of the dorsal columns of the spinal cord, leading to sensory ataxia, pain, and other neurological deficits. Accurate coding with ICD-10 Code A52.11 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and treat this condition.

What is ICD-10 Code A52.11 for Tabes dorsalis?

ICD-10 Code A52.11 represents Tabes dorsalis, a neurological disorder resulting from untreated syphilis. This code should be used when documenting cases of Tabes dorsalis in clinical settings, particularly when patients present with symptoms such as sensory loss, ataxia, and pain. Accurate coding is crucial for appropriate treatment planning and billing.

ICD-10 Code A52.11 – Clinical Definition and Explanation of Tabes dorsalis

Tabes dorsalis is caused by the degeneration of the dorsal columns of the spinal cord due to tertiary syphilis. It progresses slowly, leading to significant neurological impairment and requires prompt medical attention to manage symptoms and prevent complications.

Key Clinical Features:

• Sensory ataxia and loss of proprioception
• Lightning-like pains in the limbs
• Urinary incontinence or retention
• Arreflexia and diminished deep tendon reflexes

ICD-10 Code A52.11 for Tabes dorsalis – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code A52.11 is utilized to document the patient's symptoms, assessment findings, and treatment plans related to Tabes dorsalis. This code is relevant in both acute and chronic care settings, facilitating comprehensive patient management.

What Does ICD-10 Code A52.11 for Tabes dorsalis Mean in SOAP Notes?

ICD-10 Code A52.11 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Tabes dorsalis. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code A52.11 – Tabes dorsalis

Tabes dorsalis requires urgent medical intervention to manage symptoms and prevent further neurological damage. Treatment typically involves addressing the underlying syphilis infection and providing supportive care.

Antibiotic Therapy:

• Benzathine penicillin G: 2.4 million units IM once weekly for 3 weeks
• Alternative: Doxycycline 100 mg orally twice daily for 14 days

Supportive Care:

• Physical therapy to improve mobility and coordination
• Pain management with analgesics
• Management of urinary symptoms with catheterization if necessary

Infection Control:

• Standard precautions to prevent transmission of syphilis
• Education on safe sexual practices to prevent reinfection

How to Document Symptoms of Tabes dorsalis (ICD-10 A52.11) in SOAP Notes

Subjective:

• Patient reports episodes of severe, stabbing pain in the legs.
• Complains of difficulty walking and frequent falls.
• History of untreated syphilis with recent diagnosis.
• Reports urinary incontinence.

Objective:

• Neurological examination reveals diminished proprioception.
• Positive Romberg test indicating balance issues.
• Reflexes are absent in lower extremities.
• Gait assessment shows ataxia.

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SOAP Note Guidelines for Diagnosing Tabes dorsalis (ICD-10 Code A52.11)

Assessment:

• Diagnosis: Tabes dorsalis, moderate severity.
• ICD-10 Code: A52.11.
• Contributing factors: History of untreated syphilis.
• Triggers: Neurological degeneration due to syphilis.

Plan:

• Initiate benzathine penicillin G treatment.
• Refer to physical therapy for mobility improvement.
• Educate patient on managing urinary symptoms.
• Schedule follow-up in 4 weeks to assess treatment response.

Treatment & Plan Section for ICD-10 Code A52.11 – Tabes dorsalis

• First-line pharmacologic treatment: Benzathine penicillin G.
• Non-pharmacologic strategies: Physical therapy and pain management.
• Monitoring practices: Regular neurological assessments.
• Follow-up recommendations: Re-evaluate in 4 weeks for treatment efficacy.

Using ICD-10 Code A52.11 for Tabes dorsalis in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and history in SOAP notes.
• Use A52.11 in settings where Tabes dorsalis is diagnosed or treated.
• Align treatment plans with clinical guidelines for justified billing.
• Include relevant CPT codes that correspond with the services provided.

Related ICD-10 Codes Often Used with Tabes dorsalis

• A50.0 – Congenital syphilis, early symptomatic
• A52.0 – Late syphilis
• A52.9 – Syphilis, unspecified

ICD-10 Code A52.11 in Medical Billing and Insurance for Tabes dorsalis

ICD-10 Code A52.11 is critical for billing in hospital, ER, or infectious disease care settings, ensuring accurate reimbursement for services rendered.

Billing Notes:

• Document all relevant patient history and symptoms to support the diagnosis.
• Use A52.11 in conjunction with other codes as necessary for comprehensive billing.
• Ensure that treatment plans are clearly outlined in the medical record.
• Include any diagnostic tests performed that relate to the condition.

Common CPT Pairings: