ICD-10 Code A54.33 | Gonococcal keratitis Symptoms, Diagnosis, Billing

Gonococcal keratitis is an ocular infection caused by Neisseria gonorrhoeae, leading to inflammation of the cornea. This condition is clinically significant due to its potential to cause severe visual impairment if not promptly diagnosed and treated. The ICD-10 Code A54.33 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and track this infectious disease.

What is ICD-10 Code A54.33 for Gonococcal keratitis?

ICD-10 Code A54.33 represents Gonococcal keratitis, an infection of the cornea caused by the bacterium Neisseria gonorrhoeae. This code should be used in clinical documentation and billing when a patient presents with symptoms indicative of this condition, ensuring proper identification of the underlying infectious disease and facilitating appropriate treatment and follow-up.

ICD-10 Code A54.33 – Clinical Definition and Explanation of Gonococcal keratitis

Gonococcal keratitis is primarily caused by the direct inoculation of Neisseria gonorrhoeae into the eye, often through contact with infected genital secretions. The condition can progress rapidly, leading to corneal ulceration and potential vision loss, necessitating immediate medical attention.

Key Clinical Features:

• Acute onset of eye pain and redness
• Purulent discharge from the eye
• Photophobia and blurred vision
• Corneal opacity or ulceration on examination

ICD-10 Code A54.33 for Gonococcal keratitis – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code A54.33 is utilized to document the diagnosis of Gonococcal keratitis, 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 A54.33 for Gonococcal keratitis Mean in SOAP Notes?

ICD-10 Code A54.33 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Gonococcal keratitis. This code is essential for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A54.33 – Gonococcal keratitis

Gonococcal keratitis requires urgent medical intervention due to its infectious nature. Appropriate antibiotic therapy is critical for effective management.

Antibiotic Therapy:

• Ceftriaxone 1 g IM once or
• Ciprofloxacin 500 mg orally twice daily for 7 days
• Azithromycin 1 g orally once as an alternative
• Consider hospitalization for severe cases requiring intravenous therapy

Supportive Care:

• Topical antibiotics to manage infection
• Artificial tears to relieve dryness
• Pain management with analgesics
• Close monitoring for complications

Infection Control:

• Strict hand hygiene practices
• Avoidance of contact lens use during treatment
• Patient education on transmission prevention
• Notification of sexual partners for testing and treatment

How to Document Symptoms of Gonococcal keratitis (ICD-10 A54.33) in SOAP Notes

Subjective:

• Patient reports acute eye pain and redness
• Complains of purulent discharge from the affected eye
• Experiences photophobia and difficulty seeing clearly
• History of recent sexual contact with an infected partner

Objective:

• Visual acuity decreased in the affected eye
• Purulent conjunctival discharge observed
• Corneal examination reveals opacity and possible ulceration
• No systemic signs of infection noted

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SOAP Note Guidelines for Diagnosing Gonococcal keratitis (ICD-10 Code A54.33)

Assessment:

• Diagnosis: Gonococcal keratitis, moderate severity
• ICD-10 Code: A54.33
• Contributing factors: Recent sexual exposure, lack of protective measures
• No prior history of ocular infections noted

Plan:

• Initiate ceftriaxone 1 g IM and topical antibiotics
• Educate patient on infection control and prevention
• Schedule follow-up in 48 hours to assess treatment response
• Refer to ophthalmology for further evaluation if no improvement

Treatment & Plan Section for ICD-10 Code A54.33 – Gonococcal keratitis

• First-line treatment includes ceftriaxone and topical antibiotics.
• Non-pharmacologic strategies involve patient education on hygiene and prevention.
• Monitoring includes follow-up visits to assess visual acuity and symptom resolution.
• Consider referral to an ophthalmologist for persistent or severe cases.

Using ICD-10 Code A54.33 for Gonococcal keratitis in Billing & SOAP Note Compliance

• Select appropriate ICD-10 code based on clinical findings and documentation.
• Ensure Subjective (S) and Objective (O) sections clearly reflect symptoms and examination results.
• Align treatment plans with clinical guidelines to support justified billing.
• Document any additional services provided that may require separate CPT coding.

Related ICD-10 Codes Often Used with Gonococcal keratitis

• 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
• A54.04 – Gonococcal infection of the pharynx

ICD-10 Code A54.33 in Medical Billing and Insurance for Gonococcal keratitis

ICD-10 Code A54.33 is crucial for billing purposes in hospital, emergency room, or infectious disease care settings.

Billing Notes:

• Document all relevant patient history and clinical findings to support the diagnosis.
• Use this code in conjunction with appropriate CPT codes for services rendered.
• Ensure compliance with payer requirements for documentation and coding.
• Review coding guidelines regularly to stay updated on any changes.

Common CPT Pairings: