ICD-10 Code A54.39 | Other gonococcal eye infection Symptoms, Diagnosis, Billing

Other gonococcal eye infection is caused by the bacterium Neisseria gonorrhoeae, which can lead to conjunctivitis or keratitis. This condition is clinically significant due to its potential to cause severe ocular complications, including vision loss. Accurate coding with ICD-10 Code A54.39 ensures proper diagnosis, documentation, and billing, facilitating effective public health reporting and management of gonococcal infections.

What is ICD-10 Code A54.39 for Other gonococcal eye infection?

ICD-10 Code A54.39 represents Other gonococcal eye infection, a condition resulting from Neisseria gonorrhoeae infection affecting the eye. This code is used when the infection does not fit into more specific categories. It is essential for clinical documentation and billing when diagnosing patients with gonococcal eye infections, ensuring appropriate treatment and follow-up.

ICD-10 Code A54.39 – Clinical Definition and Explanation of Other gonococcal eye infection

Other gonococcal eye infection is primarily caused by the bacterium Neisseria gonorrhoeae, which can lead to conjunctivitis or keratitis. The condition requires prompt medical attention to prevent complications such as corneal scarring or vision impairment.

Key Clinical Features:

• Purulent discharge from the eye
• Redness and swelling of the conjunctiva
• Possible corneal involvement
• History of sexual exposure or systemic gonococcal infection

ICD-10 Code A54.39 for Other gonococcal eye infection – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code A54.39 is utilized to document the diagnosis of Other gonococcal eye infection, aiding in the assessment of symptoms and treatment plans. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management.

What Does ICD-10 Code A54.39 for Other gonococcal eye infection Mean in SOAP Notes?

ICD-10 Code A54.39 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Other gonococcal eye infection. This code is crucial for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A54.39 – Other gonococcal eye infection

Other gonococcal eye infection necessitates urgent medical intervention, often requiring hospitalization for severe cases. Appropriate antibiotic therapy is critical for effective management.

Antibiotic Therapy:

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

Supportive Care:

• Warm compresses to alleviate discomfort
• Topical lubricants to relieve dryness
• Monitoring for complications such as corneal ulceration

Infection Control:

• Strict hand hygiene practices
• Avoiding sharing personal items like towels
• Education on safe sexual practices to prevent transmission

How to Document Symptoms of Other gonococcal eye infection (ICD-10 A54.39) in SOAP Notes

Subjective:

• Patient reports purulent eye discharge
• Complains of eye redness and irritation
• History of recent sexual contact with an infected partner

Objective:

• Conjunctival injection observed on examination
• Purulent discharge noted during assessment
• Visual acuity testing shows no significant impairment

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SOAP Note Guidelines for Diagnosing Other gonococcal eye infection (ICD-10 Code A54.39)

Assessment:

• Diagnosis: Other gonococcal eye infection, moderate severity
• ICD-10 Code: A54.39
• Contributing factors: Recent sexual exposure, possible systemic infection

Plan:

• Initiate ceftriaxone 1g IM for treatment
• Educate patient on safe sexual practices
• Schedule follow-up in 1 week to monitor response to treatment

Treatment & Plan Section for ICD-10 Code A54.39 – Other gonococcal eye infection

• First-line treatment with ceftriaxone 1g IM
• Consideration of azithromycin for dual therapy
• Patient education on infection prevention
• Follow-up appointment to assess treatment efficacy

Using ICD-10 Code A54.39 for Other gonococcal eye infection in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and findings
• Use A54.39 in appropriate clinical settings for billing
• Align treatment plans with clinical guidelines for justified billing
• Include relevant CPT codes for services rendered

Related ICD-10 Codes Often Used with Other gonococcal eye infection

• 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

ICD-10 Code A54.39 in Medical Billing and Insurance for Other gonococcal eye infection

ICD-10 Code A54.39 is essential for accurate billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant symptoms and history for accurate coding
• Use A54.39 in conjunction with other relevant codes as needed
• Ensure compliance with payer requirements for documentation

Common CPT Pairings: