ICD-10 Code A54.21 | Gonococcal infection of kidney and ureter Symptoms, Diagnosis, Billing

Gonococcal infection of the kidney and ureter is a serious complication of gonorrhea, caused by the bacterium Neisseria gonorrhoeae. This condition can lead to significant morbidity if not diagnosed and treated promptly. The ICD-10 Code A54.21 facilitates accurate diagnosis, documentation, and billing, ensuring proper management of this infectious disease and aiding in public health reporting.

What is ICD-10 Code A54.21 for Gonococcal infection of kidney and ureter?

ICD-10 Code A54.21 specifically denotes a gonococcal infection affecting the kidney and ureter. This condition arises from the spread of Neisseria gonorrhoeae, typically from the lower urinary tract. This code should be utilized in clinical documentation and billing when a patient presents with symptoms indicative of this infection, ensuring appropriate treatment and follow-up.

ICD-10 Code A54.21 – Clinical Definition and Explanation of Gonococcal infection of kidney and ureter

Gonococcal infection of the kidney and ureter is primarily caused by the ascending spread of Neisseria gonorrhoeae from the urethra or bladder. This condition can lead to severe complications, including renal impairment, and requires immediate medical intervention. Early recognition and treatment are crucial to prevent long-term damage.

Key Clinical Features:

• Flank pain or tenderness
• Dysuria or urinary frequency
• Fever and chills
• Nausea or vomiting

ICD-10 Code A54.21 for Gonococcal infection of kidney and ureter – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code A54.21 is essential for documenting the patient's symptoms, assessment findings, and treatment plans. It is relevant in both acute and chronic care settings, ensuring comprehensive care and accurate billing.

What Does ICD-10 Code A54.21 for Gonococcal infection of kidney and ureter Mean in SOAP Notes?

ICD-10 Code A54.21 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of gonococcal infection of the kidney and ureter. This code supports continuity of care, facilitates billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code A54.21 – Gonococcal infection of kidney and ureter

Gonococcal infection of the kidney and ureter is a medical emergency that often necessitates hospitalization for effective management.

Antibiotic Therapy:

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

Supportive Care:

• Hydration and electrolyte management
• Pain management with analgesics
• Monitoring for renal function and complications

Infection Control:

• Strict adherence to hand hygiene
• Isolation precautions if necessary
• Education on safe sexual practices to prevent transmission

How to Document Symptoms of Gonococcal infection of kidney and ureter (ICD-10 A54.21) in SOAP Notes

Subjective:

• Patient reports flank pain and dysuria
• History of recent unprotected sexual intercourse
• Complaints of fever and chills
• Nausea and vomiting noted by the patient

Objective:

• Fever of 101°F on examination
• Tenderness in the flank area
• Positive urine culture for Neisseria gonorrhoeae
• Elevated white blood cell count

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SOAP Note Guidelines for Diagnosing Gonococcal infection of kidney and ureter (ICD-10 Code A54.21)

Assessment:

• Diagnosis: Gonococcal infection of kidney and ureter, moderate severity
• ICD-10 Code: A54.21
• Contributing factors: Recent sexual activity, possible untreated gonorrhea

Plan:

• Initiate ceftriaxone 1 g IM or IV
• Provide education on safe sexual practices
• Schedule follow-up in 1 week to monitor response to treatment
• Consider referral to infectious disease specialist if complications arise

Treatment & Plan Section for ICD-10 Code A54.21 – Gonococcal infection of kidney and ureter

• First-line treatment with ceftriaxone and azithromycin
• Patient education on the importance of completing antibiotic therapy
• Monitoring for resolution of symptoms and potential complications
• Follow-up appointments to ensure effective treatment and prevention of recurrence

Using ICD-10 Code A54.21 for Gonococcal infection of kidney and ureter in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings in SOAP notes
• Use A54.21 in conjunction with appropriate CPT codes for billing
• Document treatment plans that align with clinical guidelines to support reimbursement
• Maintain clear records of patient education and follow-up plans

Related ICD-10 Codes Often Used with Gonococcal infection of kidney and ureter

• A54.00 – Gonococcal infection of unspecified site
• A54.01 – Gonococcal infection of the urethra
• A54.02 – Gonococcal infection of the cervix
• A54.03 – Gonococcal infection of the rectum
• A54.89 – Other gonococcal infections

ICD-10 Code A54.21 in Medical Billing and Insurance for Gonococcal infection of kidney and ureter

ICD-10 Code A54.21 is crucial for billing in hospital, emergency room, or infectious disease care settings.

Billing Notes:

• Document all relevant patient history and presenting symptoms clearly
• Use A54.21 in the appropriate clinical context to support claims
• Ensure that treatment plans are well-documented to justify the use of this code

Common CPT Pairings: