Gonococcal infection of the eye, unspecified, is caused by the bacterium Neisseria gonorrhoeae. This condition is clinically significant as it can lead to severe complications, including blindness if left untreated. Accurate coding with ICD-10 Code A54.30 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can track and manage this infectious disease effectively.
What is ICD-10 Code A54.30 for Gonococcal infection of eye, unspecified?
ICD-10 Code A54.30 represents a gonococcal infection of the eye that is unspecified in nature. This condition is a result of infection by Neisseria gonorrhoeae, which can cause conjunctivitis and other ocular complications. This code should be used in clinical documentation and billing when a patient presents with symptoms of eye infection without a specified type or severity.
ICD-10 Code A54.30 – Clinical Definition and Explanation of Gonococcal infection of eye, unspecified
Gonococcal infection of the eye, unspecified, is primarily caused by the bacterium Neisseria gonorrhoeae, often transmitted through sexual contact or from mother to child during childbirth. This infection can progress rapidly, leading to serious ocular complications, necessitating prompt medical attention.
Key Clinical Features:
- Purulent conjunctival discharge
- Redness and swelling of the conjunctiva
- Possible corneal involvement
- History of sexual exposure or maternal transmission
ICD-10 Code A54.30 for Gonococcal infection of eye, unspecified – SOAP Notes & Clinical Use
ICD-10 Code A54.30 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans related to gonococcal infection of the eye. This code is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition.
What Does ICD-10 Code A54.30 for Gonococcal infection of eye, unspecified Mean in SOAP Notes?
In SOAP notes, ICD-10 Code A54.30 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of gonococcal infection of the eye. This code is crucial for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.
Treatment Options for ICD-10 Code A54.30 – Gonococcal infection of eye, unspecified
Gonococcal infection of the eye requires urgent medical intervention to prevent complications such as vision loss. Appropriate antibiotic therapy is essential for effective treatment.
Antibiotic Therapy:
- Ceftriaxone 1 g IM once
- Azithromycin 1 g orally once (alternative)
- Ciprofloxacin 500 mg orally twice daily for 7 days (alternative)
Supportive Care:
- Warm compresses to alleviate discomfort
- Topical lubricants to soothe irritation
- Monitoring for potential complications
Infection Control:
- Strict hand hygiene practices
- Avoiding contact with infected individuals
- Education on safe sexual practices to prevent transmission
How to Document Symptoms of Gonococcal infection of eye, unspecified (ICD-10 A54.30) in SOAP Notes
Subjective:
- Patient reports purulent discharge from the eye
- Complains of redness and irritation
- History of recent sexual exposure
- No previous eye infections noted
Objective:
- Conjunctival redness observed on examination
- Purulent discharge noted
- Visual acuity testing shows no significant loss
- No corneal opacity detected
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SOAP Note Guidelines for Diagnosing Gonococcal infection of eye, unspecified (ICD-10 Code A54.30)
Assessment:
- Diagnosis: Gonococcal infection of eye, unspecified, moderate severity
- ICD-10 Code: A54.30
- Contributing factors: Recent sexual exposure, lack of preventive measures
Plan:
- Initiate ceftriaxone 1 g IM for treatment
- Educate patient on safe sexual practices
- Schedule follow-up in 1 week to monitor progress
- Consider referral to ophthalmology if symptoms worsen
Treatment & Plan Section for ICD-10 Code A54.30 – Gonococcal infection of eye, unspecified
- First-line treatment with ceftriaxone IM
- Patient education on infection prevention
- Follow-up appointment to assess treatment efficacy
- Monitoring for potential complications such as corneal involvement
Using ICD-10 Code A54.30 for Gonococcal infection of eye, unspecified in Billing & SOAP Note Compliance
- Ensure accurate documentation of symptoms and history in SOAP notes
- Use A54.30 in conjunction with appropriate CPT codes for billing
- Maintain compliance with coding guidelines to support claims
- Document all relevant clinical findings to justify the diagnosis
Related ICD-10 Codes Often Used with Gonococcal infection of eye, unspecified
- A54.01 – Gonococcal conjunctivitis, right eye
- A54.02 – Gonococcal conjunctivitis, left eye
- A54.03 – Gonococcal conjunctivitis, bilateral
- A54.9 – Gonococcal infection, unspecified
ICD-10 Code A54.30 in Medical Billing and Insurance for Gonococcal infection of eye, unspecified
ICD-10 Code A54.30 is critical in medical billing, particularly in hospital, emergency room, or infectious disease care settings.
Billing Notes:
- Document all relevant patient history and symptoms clearly
- Use A54.30 in appropriate clinical settings to support claims
- Ensure that treatment plans align with coding guidelines
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 99213 | Established patient office visit, Level 3 |
| 36415 | Collection of venous blood by venipuncture |
| 87070 | Culture, bacterial; any source, except urine, blood, or stool |
Frequently Asked Questions
Common Questions About Using ICD-10 Code A54.30 for Gonococcal infection of eye, unspecified
What are the common symptoms of gonococcal infection of the eye?
Common symptoms include purulent discharge, redness of the conjunctiva, and irritation. Patients may also experience discomfort and blurred vision if the infection progresses.
How is gonococcal infection of the eye treated?
Treatment typically involves antibiotics such as ceftriaxone. Supportive care may include warm compresses and monitoring for complications.
Is gonococcal infection of the eye contagious?
Yes, gonococcal infection can be transmitted through direct contact with infected bodily fluids. It is important to practice safe sex and avoid contact with infected individuals.
When should a patient seek medical attention for eye symptoms?
Patients should seek immediate medical attention if they experience severe eye pain, significant vision changes, or if symptoms worsen despite treatment.
