Gonococcal vulvovaginitis, unspecified is an infection of the vulva and vagina caused by Neisseria gonorrhoeae. This condition is clinically significant due to its potential complications, including pelvic inflammatory disease and infertility. Accurate coding with ICD-10 Code A54.02 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring appropriate treatment and tracking of gonococcal infections.
What is ICD-10 Code A54.02 for Gonococcal vulvovaginitis, unspecified?
ICD-10 Code A54.02 represents Gonococcal vulvovaginitis, unspecified, which refers to an infection of the vulva and vagina caused by the bacterium Neisseria gonorrhoeae. This code should be used when the specific type of gonococcal vulvovaginitis is not specified, and it is essential for accurate clinical documentation and billing, particularly in cases of suspected or confirmed gonococcal infections.
ICD-10 Code A54.02 – Clinical Definition and Explanation of Gonococcal vulvovaginitis, unspecified
Gonococcal vulvovaginitis, unspecified is primarily caused by the sexually transmitted infection gonorrhea, which can lead to significant morbidity if untreated. The condition may present with various symptoms and requires prompt medical attention to prevent complications.
Key Clinical Features:
- Vulvar itching and irritation
- Vaginal discharge, often purulent
- Dysuria or painful urination
- Pelvic pain or discomfort
ICD-10 Code A54.02 for Gonococcal vulvovaginitis, unspecified – SOAP Notes & Clinical Use
ICD-10 Code A54.02 is utilized in SOAP notes to document the patient's symptoms, clinical assessment, and treatment plan for gonococcal vulvovaginitis. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management.
What Does ICD-10 Code A54.02 for Gonococcal vulvovaginitis, unspecified Mean in SOAP Notes?
In SOAP notes, ICD-10 Code A54.02 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of gonococcal vulvovaginitis. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.
Treatment Options for ICD-10 Code A54.02 – Gonococcal vulvovaginitis, unspecified
Gonococcal vulvovaginitis requires prompt treatment to prevent complications and transmission. Hospitalization may be necessary in severe cases or when complications arise.
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:
- Pain management with NSAIDs
- Hydration and rest
- Education on safe sexual practices
Infection Control:
- Advise abstinence from sexual activity until treatment is completed
- Notify sexual partners for testing and treatment
- Follow local public health guidelines for reporting
How to Document Symptoms of Gonococcal vulvovaginitis, unspecified (ICD-10 A54.02) in SOAP Notes
Subjective:
- Patient reports vulvar itching and irritation
- Vaginal discharge described as yellow and thick
- Complains of dysuria and pelvic discomfort
- History of unprotected sexual intercourse
Objective:
- Vulvar erythema and edema noted on examination
- Purulent discharge observed from the vaginal canal
- Cervical motion tenderness present
- Vital signs stable, no fever
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SOAP Note Guidelines for Diagnosing Gonococcal vulvovaginitis, unspecified (ICD-10 Code A54.02)
Assessment:
- Diagnosis: Gonococcal vulvovaginitis, unspecified, moderate severity
- ICD-10 Code: A54.02
- Contributing factors: Recent unprotected sexual intercourse
- Consider differential diagnoses such as bacterial vaginosis or candidiasis.
Plan:
- Initiate treatment with Ceftriaxone 250 mg IM
- Provide education on safe sexual practices and follow-up testing
- Schedule follow-up appointment in one week to reassess symptoms
- Consider testing for other STIs.
Treatment & Plan Section for ICD-10 Code A54.02 – Gonococcal vulvovaginitis, unspecified
- First-line treatment with Ceftriaxone and Azithromycin
- Encourage patient education on STI prevention
- Monitor for treatment response and symptom resolution
- Schedule follow-up for reassessment and partner notification.
Using ICD-10 Code A54.02 for Gonococcal vulvovaginitis, unspecified in Billing & SOAP Note Compliance
- Ensure accurate documentation of symptoms and clinical findings in SOAP notes
- Use A54.02 for billing in cases of confirmed or suspected gonococcal infection
- Align treatment plans with clinical guidelines to support justified billing
- Include relevant CPT codes that correspond to the services provided.
Related ICD-10 Codes Often Used with Gonococcal vulvovaginitis, unspecified
- A54.00 – Gonococcal vulvovaginitis, female, unspecified
- A54.01 – Gonococcal vulvovaginitis, female, acute
- A54.03 – Gonococcal vulvovaginitis, female, chronic
- A54.9 – Gonococcal infection, unspecified
ICD-10 Code A54.02 in Medical Billing and Insurance for Gonococcal vulvovaginitis, unspecified
ICD-10 Code A54.02 is crucial in medical billing, particularly in hospital, emergency room, or infectious disease care settings.
Billing Notes:
- Document all relevant patient history and symptoms clearly
- Use A54.02 in conjunction with appropriate CPT codes for services rendered
- Ensure compliance with payer guidelines for coding and billing
- Maintain accurate records to support claims and audits.
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 99213 | Established patient office visit, level 3 |
| 87591 | Nucleic acid amplification test for gonorrhea |
| 36415 | Collection of venous blood by venipuncture |
| 85025 | Complete blood count (CBC) with automated differential white blood cell count |
Frequently Asked Questions
Common Questions About Using ICD-10 Code A54.02 for Gonococcal vulvovaginitis, unspecified
What are the common symptoms of Gonococcal vulvovaginitis?
Common symptoms include vulvar itching, vaginal discharge that may be purulent, dysuria, and pelvic pain. Patients may also report discomfort during intercourse.
How is Gonococcal vulvovaginitis diagnosed?
Diagnosis is typically made through clinical evaluation and laboratory testing, including nucleic acid amplification tests (NAAT) to detect Neisseria gonorrhoeae.
What is the treatment for Gonococcal vulvovaginitis?
First-line treatment includes a single dose of Ceftriaxone and Azithromycin. Patients should be educated on safe sexual practices to prevent reinfection.
Is Gonococcal vulvovaginitis contagious?
Yes, Gonococcal vulvovaginitis is contagious and can be transmitted through sexual contact. It is important to notify sexual partners for testing and treatment.
