Gonococcal cervicitis, unspecified is an infection of the cervix caused by the bacterium Neisseria gonorrhoeae. It is clinically significant due to its potential complications, including pelvic inflammatory disease and infertility. Accurate coding with ICD-10 Code A54.03 facilitates proper diagnosis, documentation, medical billing, and public health reporting, ensuring effective management of this sexually transmitted infection.
What is ICD-10 Code A54.03 for Gonococcal cervicitis, unspecified?
ICD-10 Code A54.03 represents Gonococcal cervicitis, unspecified, which is an inflammation of the cervix due to Neisseria gonorrhoeae infection. This code is used when the specific type of cervicitis is not further specified. It is essential for clinical documentation and billing when diagnosing patients with this sexually transmitted infection.
ICD-10 Code A54.03 – Clinical Definition and Explanation of Gonococcal cervicitis, unspecified
Gonococcal cervicitis, unspecified is primarily caused by the bacterium Neisseria gonorrhoeae, which is transmitted through sexual contact. The condition can lead to serious complications if left untreated, necessitating prompt medical attention.
Key Clinical Features:
- Purulent vaginal discharge
- Cervical bleeding or spotting
- Dysuria (painful urination)
- Pelvic pain or discomfort
ICD-10 Code A54.03 for Gonococcal cervicitis, unspecified – SOAP Notes & Clinical Use
In SOAP notes, ICD-10 Code A54.03 is utilized to document the diagnosis of gonococcal cervicitis, capturing symptoms, assessment findings, and treatment plans. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management.
What Does ICD-10 Code A54.03 for Gonococcal cervicitis, unspecified Mean in SOAP Notes?
ICD-10 Code A54.03 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of gonococcal cervicitis. This code is crucial for ensuring continuity of care, supporting billing processes, and meeting EHR documentation standards.
Treatment Options for ICD-10 Code A54.03 – Gonococcal cervicitis, unspecified
Gonococcal cervicitis requires prompt treatment to prevent complications. Antibiotic therapy is the primary treatment approach.
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
Supportive Care:
- Pain management with NSAIDs
- Patient education on safe sexual practices
- Follow-up testing for reinfection
Infection Control:
- Advise patients to inform sexual partners
- Encourage safe sex practices to prevent transmission
- Consider public health reporting during outbreaks
How to Document Symptoms of Gonococcal cervicitis, unspecified (ICD-10 A54.03) in SOAP Notes
Subjective:
- Patient reports increased vaginal discharge
- Complains of dysuria and pelvic pain
- History of unprotected sexual intercourse
- No previous diagnosis of STIs
Objective:
- Cervical examination reveals purulent discharge
- Cervical motion tenderness noted
- Vital signs stable
- No fever present
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SOAP Note Guidelines for Diagnosing Gonococcal cervicitis, unspecified (ICD-10 Code A54.03)
Assessment:
- Diagnosis: Gonococcal cervicitis, unspecified, moderate severity
- ICD-10 Code: A54.03
- Contributing factors: Recent unprotected sexual activity
- No known allergies
Plan:
- Initiate ceftriaxone and azithromycin treatment
- Educate patient on safe sexual practices
- Schedule follow-up appointment in one week
- Consider testing for other STIs
Treatment & Plan Section for ICD-10 Code A54.03 – Gonococcal cervicitis, unspecified
- First-line antibiotic therapy with ceftriaxone and azithromycin
- Patient education on STI prevention and safe sex
- Monitoring for treatment efficacy and symptom resolution
- Follow-up testing for reinfection and other STIs
Using ICD-10 Code A54.03 for Gonococcal cervicitis, unspecified in Billing & SOAP Note Compliance
- Ensure accurate documentation of symptoms and clinical findings
- Use the code in appropriate clinical settings, including ER and outpatient visits
- Align treatment plans with clinical guidelines for justified billing
- Include relevant CPT codes for services rendered
Related ICD-10 Codes Often Used with Gonococcal cervicitis, unspecified
- A54.00 – Gonococcal infection of unspecified site
- A54.01 – Gonococcal infection of the urethra
- A54.02 – Gonococcal infection of the rectum
- A54.04 – Gonococcal infection of the pharynx
ICD-10 Code A54.03 in Medical Billing and Insurance for Gonococcal cervicitis, unspecified
ICD-10 Code A54.03 is essential for billing in hospital, ER, or infectious disease care settings.
Billing Notes:
- Document all relevant patient history and symptoms clearly
- Use the code in conjunction with appropriate clinical services
- Ensure compliance with payer requirements for coding
- Maintain accurate records to support claims
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 99213 | Established patient office visit, level 3 |
| 87491 | Infectious agent detection by nucleic acid (DNA or RNA), gonorrhea, amplified probe technique |
| 36415 | Collection of venous blood by venipuncture |
Frequently Asked Questions
Common Questions About Using ICD-10 Code A54.03 for Gonococcal cervicitis, unspecified
What are the common symptoms of Gonococcal cervicitis?
Common symptoms include purulent vaginal discharge, dysuria, and pelvic pain. Some patients may also experience abnormal bleeding or no symptoms at all, making regular screening important.
How is Gonococcal cervicitis treated?
Treatment typically involves antibiotics such as ceftriaxone and azithromycin. It is crucial to complete the full course of antibiotics and inform sexual partners to prevent reinfection.
Is Gonococcal cervicitis contagious?
Yes, Gonococcal cervicitis is a sexually transmitted infection and can be transmitted through sexual contact. Safe sex practices are essential to prevent its spread.
When should I seek medical attention for Gonococcal cervicitis?
Medical attention should be sought if experiencing symptoms such as unusual vaginal discharge, pelvic pain, or dysuria. Early diagnosis and treatment are important to prevent complications.
