ICD-10 Code A54.31 | Gonococcal conjunctivitis Symptoms, Diagnosis, Billing

Gonococcal conjunctivitis is an acute bacterial infection of the conjunctiva caused by Neisseria gonorrhoeae. It is clinically significant due to its potential to cause severe ocular complications and its association with systemic gonococcal infections. Accurate coding with ICD-10 Code A54.31 facilitates precise diagnosis, documentation, medical billing, and public health reporting, ensuring appropriate management and treatment.

What is ICD-10 Code A54.31 for Gonococcal conjunctivitis?

ICD-10 Code A54.31 specifically denotes gonococcal conjunctivitis, an eye infection resulting from the gonococcus bacterium. This code should be utilized in clinical documentation when a patient presents with symptoms indicative of this condition, ensuring accurate billing and tracking of infectious diseases.

ICD-10 Code A54.31 – Clinical Definition and Explanation of Gonococcal conjunctivitis

Gonococcal conjunctivitis is primarily caused by the bacterium Neisseria gonorrhoeae, often transmitted through direct contact with infected bodily fluids. The condition can progress rapidly, leading to severe complications such as corneal ulceration and potential vision loss, necessitating prompt medical intervention.

Key Clinical Features:

• Purulent discharge from the eye
• Redness and swelling of the conjunctiva
• Possible eyelid edema
• History of recent sexual contact or systemic gonococcal infection

ICD-10 Code A54.31 for Gonococcal conjunctivitis – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code A54.31 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 patient management and accurate billing.

What Does ICD-10 Code A54.31 for Gonococcal conjunctivitis Mean in SOAP Notes?

ICD-10 Code A54.31 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of gonococcal conjunctivitis. This code is crucial for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A54.31 – Gonococcal conjunctivitis

Gonococcal conjunctivitis requires urgent medical attention due to its infectious nature. Appropriate antibiotic therapy is critical for effective treatment.

Antibiotic Therapy:

• Ceftriaxone 1 g IM once
• Azithromycin 1 g orally once (alternative)
• Ciprofloxacin 500 mg orally once (alternative)
• Doxycycline 100 mg orally twice daily for 7 days (alternative)

Supportive Care:

• Warm compresses to alleviate discomfort
• Topical lubricants to soothe irritation
• Monitoring for complications such as corneal involvement

Infection Control:

• Strict hand hygiene practices
• Avoiding sharing personal items like towels
• Isolation precautions during outbreaks

How to Document Symptoms of Gonococcal conjunctivitis (ICD-10 A54.31) in SOAP Notes

Subjective:

• Patient reports purulent discharge from the eye
• Complaints of redness and irritation
• History of recent sexual contact
• No previous eye infections noted

Objective:

• Conjunctival injection observed on examination
• Purulent discharge noted during assessment
• Eyelid edema present
• Visual acuity testing within normal limits

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SOAP Note Guidelines for Diagnosing Gonococcal conjunctivitis (ICD-10 Code A54.31)

Assessment:

• Diagnosis: Gonococcal conjunctivitis, acute
• ICD-10 Code: A54.31
• Contributing factors: Recent sexual contact, potential exposure to infection
• Severity: Moderate

Plan:

• Initiate ceftriaxone 1 g IM for treatment
• Educate patient on infection control measures
• Schedule follow-up in 48 hours to reassess symptoms
• Consider referral to ophthalmology if symptoms worsen

Treatment & Plan Section for ICD-10 Code A54.31 – Gonococcal conjunctivitis

• First-line antibiotic therapy with ceftriaxone
• Patient education on safe sexual practices
• Monitoring for potential complications such as corneal damage
• Follow-up appointment to ensure resolution of symptoms

Using ICD-10 Code A54.31 for Gonococcal conjunctivitis in Billing & SOAP Note Compliance

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

Related ICD-10 Codes Often Used with Gonococcal conjunctivitis

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

ICD-10 Code A54.31 in Medical Billing and Insurance for Gonococcal conjunctivitis

ICD-10 Code A54.31 is crucial for billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Ensure documentation includes all relevant symptoms and treatment details
• Use the code in conjunction with appropriate CPT codes for services rendered
• Verify that the diagnosis aligns with the patient's clinical presentation
• Maintain accurate records to support insurance claims

Common CPT Pairings: