ICD-10 Code A54.22 | Gonococcal prostatitis Symptoms, Diagnosis, Billing

Gonococcal prostatitis is an infection of the prostate gland caused by Neisseria gonorrhoeae, a sexually transmitted bacterium. This condition is clinically significant due to its potential complications, including infertility and chronic pelvic pain. Accurate coding with ICD-10 Code A54.22 ensures proper diagnosis, documentation, and billing, facilitating effective public health reporting and management of gonococcal infections.

What is ICD-10 Code A54.22 for Gonococcal prostatitis?

ICD-10 Code A54.22 specifically denotes gonococcal prostatitis, an inflammation of the prostate gland resulting from gonococcal infection. This code should be used when documenting cases of prostatitis linked to Neisseria gonorrhoeae, ensuring accurate representation of the patient's condition for clinical documentation and billing purposes.

ICD-10 Code A54.22 – Clinical Definition and Explanation of Gonococcal prostatitis

Gonococcal prostatitis is primarily caused by the sexually transmitted bacterium Neisseria gonorrhoeae. The infection can lead to acute or chronic prostatitis, necessitating prompt medical attention to prevent complications such as abscess formation or systemic infection.

Key Clinical Features:

• Dysuria or painful urination
• Pelvic pain or discomfort
• Fever and chills
• Purulent discharge from the urethra

ICD-10 Code A54.22 for Gonococcal prostatitis – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code A54.22 is utilized to document the diagnosis of gonococcal prostatitis, aiding in the assessment of symptoms, clinical findings, and treatment plans. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management.

What Does ICD-10 Code A54.22 for Gonococcal prostatitis Mean in SOAP Notes?

ICD-10 Code A54.22 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of gonococcal prostatitis. This code is essential for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A54.22 – Gonococcal prostatitis

Gonococcal prostatitis 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
• Doxycycline 100 mg orally twice daily for 7 days (alternative)

Supportive Care:

• Hydration and analgesics for pain relief
• Warm sitz baths to alleviate discomfort
• Education on safe sexual practices

Infection Control:

• Advise patients to inform sexual partners
• Encourage testing and treatment of partners
• Implement safe sex practices to prevent transmission

How to Document Symptoms of Gonococcal prostatitis (ICD-10 A54.22) in SOAP Notes

Subjective:

• Patient reports dysuria and pelvic pain
• History of recent unprotected sexual intercourse
• Complaints of fever and chills
• Noted purulent urethral discharge

Objective:

• Tenderness on palpation of the prostate
• Elevated temperature (e.g., 101°F)
• Purulent discharge observed during examination
• Urinalysis shows leukocytes and bacteria

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SOAP Note Guidelines for Diagnosing Gonococcal prostatitis (ICD-10 Code A54.22)

Assessment:

• Diagnosis: Gonococcal prostatitis, acute
• ICD-10 Code: A54.22
• Contributing factors: Recent sexual activity without protection
• Severity: Moderate

Plan:

• Initiate ceftriaxone and azithromycin treatment
• Educate patient on safe sexual practices
• Schedule follow-up in one week to reassess symptoms
• Consider referral to urology if symptoms persist

Treatment & Plan Section for ICD-10 Code A54.22 – Gonococcal prostatitis

• First-line pharmacologic treatment includes ceftriaxone and azithromycin
• Non-pharmacologic strategies involve patient education on safe sex
• Monitoring includes follow-up visits to assess treatment efficacy
• Consider additional testing for other STIs as indicated

Using ICD-10 Code A54.22 for Gonococcal prostatitis in Billing & SOAP Note Compliance

• Select appropriate ICD-10 code based on clinical findings
• Document symptoms clearly in Subjective (S) and Objective (O) sections
• Ensure treatment plans align with clinical guidelines for justified billing
• Include relevant CPT codes that correspond with the diagnosis and treatment

Related ICD-10 Codes Often Used with Gonococcal prostatitis

• A54.00 – Gonococcal infection of unspecified site
• A54.01 – Gonococcal infection of the urethra
• A54.03 – Gonococcal infection of the cervix
• A54.21 – Gonococcal epididymitis

ICD-10 Code A54.22 in Medical Billing and Insurance for Gonococcal prostatitis

ICD-10 Code A54.22 is crucial for accurate billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Ensure documentation includes patient history and presenting symptoms
• Use the code in conjunction with relevant CPT codes for services rendered
• Maintain clear records of treatment plans and follow-up care
• Document any complications or additional diagnoses

Common CPT Pairings: