ICD-10 Code A54.01 | Gonococcal cystitis and urethritis, unspecified Symptoms, Diagnosis, Billing

Gonococcal cystitis and urethritis, unspecified is an infection caused by Neisseria gonorrhoeae, primarily affecting the bladder and urethra. This condition is clinically significant due to its potential complications, including infertility and increased susceptibility to HIV. Accurate coding with ICD-10 Code A54.01 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and treat this infection.

What is ICD-10 Code A54.01 for Gonococcal cystitis and urethritis, unspecified?

ICD-10 Code A54.01 represents Gonococcal cystitis and urethritis, unspecified, which refers to an infection of the urinary tract caused by Neisseria gonorrhoeae. This code is used when the specific site of infection is not detailed, and it is crucial for accurate clinical documentation and billing. It should be applied when a patient presents with symptoms of urinary tract infection without specifying the exact nature of the gonococcal infection.

ICD-10 Code A54.01 – Clinical Definition and Explanation of Gonococcal cystitis and urethritis, unspecified

Gonococcal cystitis and urethritis, unspecified, is primarily caused by the sexually transmitted bacterium Neisseria gonorrhoeae. This infection can lead to significant morbidity if left untreated, necessitating prompt medical attention. The condition may progress to more severe complications, including pelvic inflammatory disease and infertility.

Key Clinical Features:

• Dysuria (painful urination)
• Increased urinary frequency
• Urethral discharge
• Pelvic pain or discomfort

ICD-10 Code A54.01 for Gonococcal cystitis and urethritis, unspecified – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code A54.01 is utilized to document the patient's symptoms, assessment findings, and treatment plans related to gonococcal cystitis and urethritis. This code is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition.

What Does ICD-10 Code A54.01 for Gonococcal cystitis and urethritis, unspecified Mean in SOAP Notes?

ICD-10 Code A54.01 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of gonococcal cystitis and urethritis. This code is essential for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A54.01 – Gonococcal cystitis and urethritis, unspecified

Gonococcal cystitis and urethritis requires prompt treatment to prevent complications. Hospitalization may be necessary in severe cases, and appropriate antibiotic therapy is critical.

Antibiotic Therapy:

• Ceftriaxone 250 mg IM once
• Azithromycin 1 g orally once (alternative)
• Doxycycline 100 mg orally twice daily for 7 days (alternative)

Supportive Care:

• Hydration to alleviate symptoms
• Pain management with NSAIDs
• Patient education on safe sexual practices

Infection Control:

• Notify sexual partners for testing and treatment
• Practice safe sex to prevent transmission
• Follow local public health guidelines during outbreaks

How to Document Symptoms of Gonococcal cystitis and urethritis, unspecified (ICD-10 A54.01) in SOAP Notes

Subjective:

• Patient reports dysuria and increased urinary frequency
• History of unprotected sexual intercourse
• Complaints of urethral discharge
• No prior history of similar symptoms

Objective:

• Urethral discharge observed on examination
• Urinalysis shows leukocytes and nitrates
• No fever or systemic signs of infection
• Pelvic examination reveals tenderness

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SOAP Note Guidelines for Diagnosing Gonococcal cystitis and urethritis, unspecified (ICD-10 Code A54.01)

Assessment:

• Diagnosis: Gonococcal cystitis and urethritis, unspecified, moderate severity
• ICD-10 Code: A54.01
• Contributing factors: Recent unprotected sexual activity
• No known drug allergies noted

Plan:

• Initiate treatment with Ceftriaxone 250 mg IM
• Educate patient on safe sexual practices
• Schedule follow-up in one week to reassess symptoms
• Consider testing for other STIs

Treatment & Plan Section for ICD-10 Code A54.01 – Gonococcal cystitis and urethritis, unspecified

• First-line treatment with Ceftriaxone and Azithromycin
• Patient education on infection prevention and safe sex
• Monitoring for symptom resolution and potential complications
• Follow-up testing for reinfection or other STIs

Using ICD-10 Code A54.01 for Gonococcal cystitis and urethritis, unspecified in Billing & SOAP Note Compliance

• Select appropriate ICD-10 code based on clinical findings
• Document symptoms clearly under Subjective (S) and Objective (O)
• Ensure treatment plans align with clinical guidelines for justified billing
• Include relevant CPT codes for services rendered

Related ICD-10 Codes Often Used with Gonococcal cystitis and urethritis, unspecified

• A54.00 – Gonococcal cystitis and urethritis, unspecified, without complications
• A54.02 – Gonococcal cystitis and urethritis, with complications
• A54.03 – Gonococcal cystitis and urethritis, recurrent
• A54.9 – Gonococcal infection, unspecified

ICD-10 Code A54.01 in Medical Billing and Insurance for Gonococcal cystitis and urethritis, unspecified

ICD-10 Code A54.01 is crucial in medical billing, particularly in hospital, ER, or infectious disease care settings.

Billing Notes:

• Ensure accurate documentation of symptoms and treatment
• Use in conjunction with appropriate CPT codes for services
• Verify coding compliance with payer guidelines
• Document patient education and follow-up plans

Common CPT Pairings: