ICD-10 Code A54.00 | Gonococcal infection of lower genitourinary tract, unsp Symptoms, Diagnosis, Billing

Gonococcal infection of the lower genitourinary tract, unspecified, is caused by the bacterium Neisseria gonorrhoeae. This sexually transmitted infection can lead to significant morbidity if left untreated, including pelvic inflammatory disease and infertility. Accurate coding with ICD-10 Code A54.00 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that patients receive appropriate care and follow-up.

What is ICD-10 Code A54.00 for Gonococcal infection of lower genitourinary tract, unsp?

ICD-10 Code A54.00 represents a gonococcal infection of the lower genitourinary tract, unspecified. This code is used when a patient presents with symptoms consistent with gonorrhea but without further specification of the site or severity. It is crucial for clinical documentation and billing, particularly in cases where the infection may lead to complications or requires specific treatment protocols.

ICD-10 Code A54.00 – Clinical Definition and Explanation of Gonococcal infection of lower genitourinary tract, unsp

Gonococcal infection of the lower genitourinary tract, unspecified, is primarily caused by the bacterium Neisseria gonorrhoeae, transmitted through sexual contact. The infection can progress rapidly, leading to serious complications if not treated promptly. Medical attention is essential to prevent long-term health issues.

Key Clinical Features:

• Purulent discharge from the urethra or cervix.
• Dysuria or painful urination.
• Pelvic pain or discomfort.
• Increased urinary frequency.

ICD-10 Code A54.00 for Gonococcal infection of lower genitourinary tract, unsp – SOAP Notes & Clinical Use

ICD-10 Code A54.00 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans. It is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition and facilitating appropriate management.

What Does ICD-10 Code A54.00 for Gonococcal infection of lower genitourinary tract, unsp Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A54.00 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of gonococcal infection. This code supports continuity of care, aids in billing processes, and meets EHR documentation standards.

Treatment Options for ICD-10 Code A54.00 – Gonococcal infection of lower genitourinary tract, unsp

Prompt treatment of gonococcal infection is critical to prevent complications. Hospitalization may be required in severe cases, and appropriate antibiotic therapy is essential.

Antibiotic Therapy:

• Ceftriaxone 250 mg IM in a single dose.
• Azithromycin 1 g orally in a single dose (alternative).
• Doxycycline 100 mg orally twice daily for 7 days (alternative for chlamydia co-infection).

Supportive Care:

• Hydration and pain management.
• Patient education on safe sexual practices.
• Follow-up testing to ensure treatment efficacy.

Infection Control:

• Encourage abstinence from sexual activity until treatment is completed.
• Notify sexual partners for testing and treatment.
• Implement safe sex practices to prevent future infections.

How to Document Symptoms of Gonococcal infection of lower genitourinary tract, unsp (ICD-10 A54.00) in SOAP Notes

Subjective:

• Patient reports dysuria and increased urinary frequency.
• Noted purulent discharge from the urethra.
• History of unprotected sexual intercourse.
• Complaints of pelvic discomfort.

Objective:

• Physical examination reveals erythema and discharge.
• Urinalysis shows leukocytes and bacteria.
• Cervical examination indicates tenderness.
• Vital signs stable with no fever.

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SOAP Note Guidelines for Diagnosing Gonococcal infection of lower genitourinary tract, unsp (ICD-10 Code A54.00)

Assessment:

• Diagnosis: Gonococcal infection of lower genitourinary tract, unspecified, moderate severity.
• ICD-10 Code: A54.00.
• Contributing factors: Recent unprotected sexual activity.
• Potential complications: Risk of pelvic inflammatory disease.

Plan:

• Initiate ceftriaxone 250 mg IM and azithromycin 1 g orally.
• Educate patient on safe sexual practices and the importance of partner notification.
• Schedule follow-up appointment in one week for reassessment.
• Consider testing for other STIs.

Treatment & Plan Section for ICD-10 Code A54.00 – Gonococcal infection of lower genitourinary tract, unsp

• First-line treatment includes ceftriaxone and azithromycin.
• Patient education on safe sexual practices is essential.
• Follow-up testing is necessary to confirm treatment success.
• Monitor for potential complications such as PID.

Using ICD-10 Code A54.00 for Gonococcal infection of lower genitourinary tract, unsp in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings.
• Use A54.00 in appropriate clinical settings, including outpatient and emergency care.
• Align treatment plans with clinical guidelines to support billing.
• Include relevant CPT codes for services rendered.

Related ICD-10 Codes Often Used with Gonococcal infection of lower genitourinary tract, unsp

• A54.01 – Gonococcal infection of lower genitourinary tract, male
• A54.02 – Gonococcal infection of lower genitourinary tract, female
• A54.03 – Gonococcal infection of lower genitourinary tract, unspecified site
• A54.9 – Gonococcal infection, unspecified

ICD-10 Code A54.00 in Medical Billing and Insurance for Gonococcal infection of lower genitourinary tract, unsp

ICD-10 Code A54.00 is critical in medical billing, particularly in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant symptoms and clinical findings to support the diagnosis.
• Use A54.00 in settings where gonococcal infection is suspected or confirmed.
• Ensure that treatment plans are clearly outlined in the patient's record.
• Include follow-up care and patient education in documentation.

Common CPT Pairings: