ICD-10 Code A54.09 | Other gonococcal infection of lower genitourinary tract Symptoms, Diagnosis, Billing

Other gonococcal infection of the lower genitourinary tract is primarily caused by the bacterium Neisseria gonorrhoeae. This condition is clinically significant as it can lead to serious complications such as pelvic inflammatory disease, infertility, and increased susceptibility to HIV. The ICD-10 Code A54.09 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively track and manage this infection.

What is ICD-10 Code A54.09 for Other gonococcal infection of lower genitourinary tract?

ICD-10 Code A54.09 represents Other gonococcal infection of the lower genitourinary tract, which includes infections not classified elsewhere. This code is used when a patient presents with symptoms indicative of gonococcal infection affecting the lower urinary tract, such as urethritis or cervicitis, and is essential for accurate clinical documentation and billing.

ICD-10 Code A54.09 – Clinical Definition and Explanation of Other gonococcal infection of lower genitourinary tract

Other gonococcal infection of the lower genitourinary tract is caused by Neisseria gonorrhoeae, a sexually transmitted bacterium. The infection can progress to more severe conditions if left untreated, necessitating prompt medical attention.

Key Clinical Features:

• Urethral discharge, often purulent in nature.
• Dysuria or painful urination.
• Pelvic pain or discomfort in females.
• Increased urinary frequency or urgency.

ICD-10 Code A54.09 for Other gonococcal infection of lower genitourinary tract – SOAP Notes & Clinical Use

ICD-10 Code A54.09 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 patient management.

What Does ICD-10 Code A54.09 for Other gonococcal infection of lower genitourinary tract Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A54.09 connects subjective patient-reported symptoms with objective clinical findings, facilitating a formal diagnosis. This code is crucial for ensuring continuity of care, supporting billing processes, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A54.09 – Other gonococcal infection of lower genitourinary tract

Prompt treatment of Other gonococcal infection of the lower genitourinary tract is essential to prevent complications. Antibiotic therapy is the primary treatment modality.

Antibiotic Therapy:

• Ceftriaxone 250 mg IM as a single dose.
• Azithromycin 1 g orally as a single dose.
• Alternative: Doxycycline 100 mg orally twice daily for 7 days.

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 reinfection.

How to Document Symptoms of Other gonococcal infection of lower genitourinary tract (ICD-10 A54.09) in SOAP Notes

Subjective:

• Patient reports purulent urethral discharge.
• Complaints of dysuria and increased urinary frequency.
• History of unprotected sexual intercourse.
• No previous history of gonococcal infections.

Objective:

• Physical examination reveals erythema of the urethral meatus.
• Purulent discharge observed upon examination.
• No abdominal tenderness or fever noted.
• Urinalysis shows leukocytes and nitrates.

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SOAP Note Guidelines for Diagnosing Other gonococcal infection of lower genitourinary tract (ICD-10 Code A54.09)

Assessment:

• Diagnosis: Other gonococcal infection of lower genitourinary tract, moderate severity.
• ICD-10 Code: A54.09.
• Contributing factors: Recent unprotected sexual contact.
• No known allergies to antibiotics.

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 A54.09 – Other gonococcal infection of lower genitourinary tract

• First-line treatment includes ceftriaxone and azithromycin.
• Patient education on the importance of completing the antibiotic course.
• Monitoring for symptom resolution and potential complications.
• Follow-up testing for reinfection or treatment failure.

Using ICD-10 Code A54.09 for Other gonococcal infection of lower genitourinary tract in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings in SOAP notes.
• Use the code in settings where gonococcal infections are diagnosed and treated.
• Align treatment plans with clinical guidelines to support justified billing.
• Include relevant CPT codes for laboratory tests and consultations.

Related ICD-10 Codes Often Used with Other gonococcal infection of lower genitourinary tract

• A54.00 – Unspecified gonococcal infection of lower genitourinary tract
• A54.01 – Gonococcal urethritis
• A54.02 – Gonococcal cervicitis
• A54.03 – Gonococcal pelvic inflammatory disease

ICD-10 Code A54.09 in Medical Billing and Insurance for Other gonococcal infection of lower genitourinary tract

ICD-10 Code A54.09 is critical in medical billing, particularly in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant patient history and clinical findings to support the use of this code.
• Use the code in conjunction with appropriate CPT codes for laboratory tests and treatments.
• Ensure compliance with payer guidelines for documentation and coding.
• Review coding updates regularly to maintain accuracy.

Common CPT Pairings: