ICD-10 Code A54.42 | Gonococcal arthritis Symptoms, Diagnosis, Billing

Gonococcal arthritis is a joint infection caused by the bacterium Neisseria gonorrhoeae, typically resulting from disseminated gonococcal infection. This condition is clinically significant due to its potential to cause joint damage and systemic complications if left untreated. The ICD-10 Code A54.42 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively track and manage this infectious disease.

What is ICD-10 Code A54.42 for Gonococcal arthritis?

ICD-10 Code A54.42 specifically represents Gonococcal arthritis, a complication arising from the systemic spread of Neisseria gonorrhoeae. This code should be used in clinical documentation and billing when a patient presents with joint pain and swelling associated with a confirmed gonococcal infection, ensuring proper treatment and management of the condition.

ICD-10 Code A54.42 – Clinical Definition and Explanation of Gonococcal arthritis

Gonococcal arthritis is primarily caused by the dissemination of Neisseria gonorrhoeae, leading to inflammation of the joints. It often presents with acute onset of joint pain, swelling, and systemic symptoms, necessitating prompt medical attention to prevent complications such as chronic arthritis or systemic infection.

Key Clinical Features:

• Acute onset of joint pain and swelling, often affecting the knees, wrists, or ankles.
• Presence of systemic symptoms such as fever and malaise.
• History of recent gonococcal infection or risk factors for sexually transmitted infections.
• Possible skin lesions or tenosynovitis accompanying joint symptoms.

ICD-10 Code A54.42 for Gonococcal arthritis – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code A54.42 is utilized to document the patient's symptoms, assessment findings, and treatment plans related to Gonococcal arthritis. This code is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition and facilitating appropriate billing.

What Does ICD-10 Code A54.42 for Gonococcal arthritis Mean in SOAP Notes?

ICD-10 Code A54.42 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Gonococcal arthritis. This code is essential for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A54.42 – Gonococcal arthritis

Gonococcal arthritis requires urgent medical intervention, often necessitating hospitalization for severe cases. Appropriate antibiotic therapy is critical to manage the infection effectively.

Antibiotic Therapy:

• Ceftriaxone 1g IV or IM once, plus Azithromycin 1g orally once.
• Alternative: Gentamicin 240mg IM once, plus Azithromycin 1g orally once.
• Duration typically ranges from 7 to 14 days, depending on clinical response.

Supportive Care:

• Rest and immobilization of affected joints to reduce pain.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management.
• Physical therapy to restore joint function post-infection.

Infection Control:

• Educate patients on safe sexual practices to prevent transmission.
• Screen and treat sexual partners to reduce reinfection risk.
• Implement public health measures during outbreaks to control spread.

How to Document Symptoms of Gonococcal arthritis (ICD-10 A54.42) in SOAP Notes

Subjective:

• Patient reports sudden onset of joint pain, primarily in the knees.
• History of recent unprotected sexual intercourse.
• Complaints of fever and fatigue over the past few days.
• Notable swelling and tenderness in affected joints.

Objective:

• Swelling and erythema noted in the right knee joint.
• Temperature recorded at 101°F.
• Limited range of motion in affected joints observed.
• Positive synovial fluid analysis for Neisseria gonorrhoeae.

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SOAP Note Guidelines for Diagnosing Gonococcal arthritis (ICD-10 Code A54.42)

Assessment:

• Diagnosis: Gonococcal arthritis, moderate severity.
• ICD-10 Code: A54.42.
• Contributing factors: Recent gonococcal infection, lack of treatment.
• Consideration of potential complications if untreated.

Plan:

• Initiate antibiotic therapy as per guidelines.
• Educate patient on the importance of completing the antibiotic course.
• Schedule follow-up appointment in one week to assess treatment response.
• Refer to infectious disease specialist if no improvement.

Treatment & Plan Section for ICD-10 Code A54.42 – Gonococcal arthritis

• First-line pharmacologic treatment includes Ceftriaxone and Azithromycin.
• Non-pharmacologic strategies include joint rest and NSAIDs for pain relief.
• Monitoring includes assessing joint function and symptom resolution.
• Follow-up practices involve regular check-ups to prevent recurrence.

Using ICD-10 Code A54.42 for Gonococcal arthritis in Billing & SOAP Note Compliance

• Select accurate subcodes based on clinical severity or complications.
• Document symptoms clearly under Subjective (S) and Objective (O) in SOAP notes.
• Ensure treatment plans align with clinical guidelines to support justified billing.
• Only list CPT codes that are commonly billed with ICD-10 Code A54.42 based on standard medical coding practices.

Related ICD-10 Codes Often Used with Gonococcal arthritis

• A54.00 – Gonococcal infection of unspecified site
• A54.01 – Gonococcal infection of the lower genitourinary tract
• A54.03 – Gonococcal infection of the rectum
• A54.02 – Gonococcal infection of the pharynx

ICD-10 Code A54.42 in Medical Billing and Insurance for Gonococcal arthritis

ICD-10 Code A54.42 is crucial for billing in hospital, ER, or infectious disease care settings, ensuring accurate reimbursement for services rendered.

Billing Notes:

• Document all relevant patient history and clinical findings to support the use of this code.
• Use this code in conjunction with appropriate CPT codes for comprehensive billing.
• Ensure that the diagnosis is clearly linked to the treatment provided in the medical record.
• Review payer-specific guidelines for any additional documentation requirements.

Common CPT Pairings: