ICD-10 Code A52.9 | Late syphilis, unspecified Symptoms, Diagnosis, Billing

Late syphilis, unspecified, is a stage of syphilis characterized by systemic involvement, which can lead to severe complications if untreated. It is caused by the bacterium Treponema pallidum and is clinically significant due to its potential to cause serious health issues, including cardiovascular and neurological damage. The ICD-10 Code A52.9 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring that patients receive appropriate care and follow-up.

What is ICD-10 Code A52.9 for Late syphilis, unspecified?

ICD-10 Code A52.9 represents Late syphilis, unspecified, which refers to the advanced stage of syphilis where the infection has progressed without specific manifestations being documented. This code should be used when a patient presents with late-stage syphilis symptoms but lacks detailed classification. It is essential for clinical documentation and billing to ensure proper treatment and management of the underlying disease.

ICD-10 Code A52.9 – Clinical Definition and Explanation of Late syphilis, unspecified

Late syphilis, unspecified, occurs when syphilis remains untreated for years, leading to severe systemic complications. The condition requires immediate medical attention to prevent further health deterioration. It is primarily caused by the bacterium Treponema pallidum and can progress to affect multiple organ systems.

Key Clinical Features:

• Cardiovascular complications such as aortitis
• Neurological manifestations including tabes dorsalis
• Gummatous lesions affecting skin and organs
• Potential for transmission during sexual contact

ICD-10 Code A52.9 for Late syphilis, unspecified – SOAP Notes & Clinical Use

ICD-10 Code A52.9 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans. It plays a crucial role in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition and facilitating appropriate management strategies.

What Does ICD-10 Code A52.9 for Late syphilis, unspecified Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A52.9 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of late syphilis. This code is vital for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A52.9 – Late syphilis, unspecified

Late syphilis requires prompt treatment to prevent serious complications. Hospitalization may be necessary for severe cases.

Antibiotic Therapy:

• Benzathine penicillin G 2.4 million units IM once weekly for 3 weeks
• Doxycycline 100 mg orally twice daily for 28 days (alternative)
• Tetracycline 500 mg orally four times daily for 28 days (alternative)

Supportive Care:

• Pain management for associated symptoms
• Monitoring for neurological or cardiovascular complications
• Patient education on disease transmission and prevention

Infection Control:

• Implement safe sex practices to prevent transmission
• Educate patients on the importance of notifying sexual partners
• Follow local public health guidelines during outbreaks

How to Document Symptoms of Late syphilis, unspecified (ICD-10 A52.9) in SOAP Notes

Subjective:

• Patient reports fatigue and weight loss
• History of untreated syphilis for several years
• Complaints of headaches and visual disturbances

Objective:

• Physical examination reveals skin lesions consistent with gummas
• Neurological exam shows diminished reflexes
• Cardiovascular assessment indicates a systolic murmur

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SOAP Note Guidelines for Diagnosing Late syphilis, unspecified (ICD-10 Code A52.9)

Assessment:

• Diagnosis of Late syphilis, unspecified (ICD-10 A52.9)
• Severity classified as advanced due to systemic involvement
• Contributing factors include lack of prior treatment

Plan:

• Initiate benzathine penicillin G treatment
• Schedule follow-up appointments for monitoring treatment response
• Educate patient on safe sexual practices and partner notification

Treatment & Plan Section for ICD-10 Code A52.9 – Late syphilis, unspecified

• First-line treatment with benzathine penicillin G
• Consider alternative antibiotics for penicillin-allergic patients
• Regular follow-up to monitor for treatment efficacy
• Patient education on disease management and prevention

Using ICD-10 Code A52.9 for Late syphilis, unspecified in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings
• Use A52.9 in conjunction with appropriate CPT codes for billing
• Align treatment plans with clinical guidelines to support justified billing
• Document any complications or additional diagnoses clearly

Related ICD-10 Codes Often Used with Late syphilis, unspecified

• A52.0 – Early syphilis
• A52.1 – Late syphilis with cardiovascular involvement
• A52.2 – Late syphilis with neurological involvement
• A52.8 – Other late syphilis

ICD-10 Code A52.9 in Medical Billing and Insurance for Late syphilis, unspecified

ICD-10 Code A52.9 is crucial for billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant patient history and symptoms clearly
• Use A52.9 in appropriate clinical settings to support claims
• Ensure all chart elements align with coding guidelines

Common CPT Pairings: