ICD-10 Code A54.6 | Gonococcal infection of anus and rectum Symptoms, Diagnosis, Billing

Gonococcal infection of the anus and rectum is caused by the bacterium Neisseria gonorrhoeae, primarily transmitted through sexual contact. This condition is clinically significant due to its potential complications, including proctitis and increased risk of HIV transmission. Accurate coding with ICD-10 Code A54.6 ensures proper diagnosis, documentation, and billing, facilitating effective public health reporting and management of sexually transmitted infections.

What is ICD-10 Code A54.6 for Gonococcal infection of anus and rectum?

ICD-10 Code A54.6 specifically denotes a gonococcal infection localized to the anus and rectum. This condition arises from the transmission of Neisseria gonorrhoeae and can lead to significant morbidity if untreated. The code should be utilized in clinical documentation when a patient presents with symptoms indicative of this infection, ensuring accurate billing and appropriate management.

ICD-10 Code A54.6 – Clinical Definition and Explanation of Gonococcal infection of anus and rectum

Gonococcal infection of the anus and rectum is primarily caused by the bacterium Neisseria gonorrhoeae, often resulting from anal intercourse. The infection can lead to inflammation and complications if not treated promptly. Medical attention is crucial to prevent further health issues and transmission of the infection.

Key Clinical Features:

• Anal pain or discomfort
• Rectal bleeding or discharge
• Itching or irritation in the anal area
• Possible fever or systemic symptoms

ICD-10 Code A54.6 for Gonococcal infection of anus and rectum – SOAP Notes & Clinical Use

ICD-10 Code A54.6 is integral in SOAP notes 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 A54.6 for Gonococcal infection of anus and rectum Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A54.6 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of gonococcal infection. This code supports continuity of care, facilitates billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code A54.6 – Gonococcal infection of anus and rectum

Prompt treatment of gonococcal infection of the anus and rectum is essential to prevent complications. Antibiotic therapy is the primary treatment modality.

Antibiotic Therapy:

• Ceftriaxone 250 mg IM once
• Azithromycin 1 g orally once (alternative)
• Doxycycline 100 mg orally twice daily for 7 days (alternative)

Supportive Care:

• Pain management with NSAIDs
• Hydration and rest
• Education on safe sexual practices

Infection Control:

• Advise on abstaining from sexual activity until treatment is completed
• Encourage partner notification and treatment
• Implement safe sex practices to prevent future infections

How to Document Symptoms of Gonococcal infection of anus and rectum (ICD-10 A54.6) in SOAP Notes

Subjective:

• Patient reports anal pain and discomfort
• Noted rectal discharge and itching
• History of recent unprotected anal intercourse
• Patient expresses concern about potential STIs

Objective:

• Tenderness on rectal examination
• Presence of purulent discharge from the rectum
• Vital signs stable; no fever noted
• Swelling or erythema in the anal region

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SOAP Note Guidelines for Diagnosing Gonococcal infection of anus and rectum (ICD-10 Code A54.6)

Assessment:

• Diagnosis: Gonococcal infection of anus and rectum, moderate severity
• ICD-10 Code: A54.6
• Contributing factors: Recent unprotected sexual activity
• Consider differential diagnoses such as other STIs

Plan:

• Initiate ceftriaxone 250 mg IM and azithromycin 1 g orally
• Educate patient on safe sexual practices
• Schedule follow-up in one week to reassess symptoms
• Advise partner notification and treatment

Treatment & Plan Section for ICD-10 Code A54.6 – Gonococcal infection of anus and rectum

• First-line treatment with ceftriaxone and azithromycin
• Patient education on STI prevention and safe sex practices
• Monitoring for symptom resolution and potential complications
• Follow-up appointment to ensure treatment efficacy

Using ICD-10 Code A54.6 for Gonococcal infection of anus and rectum in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings
• Use A54.6 in appropriate clinical settings, including ER and outpatient visits
• Align treatment plans with clinical guidelines for justified billing
• Include relevant CPT codes that correspond to the services provided

Related ICD-10 Codes Often Used with Gonococcal infection of anus and rectum

• A54.0 – Gonococcal infection of the pharynx
• A54.1 – Gonococcal infection of the cervix
• A54.2 – Gonococcal infection of the urethra
• A54.3 – Gonococcal infection of the female genital tract
• A54.9 – Gonococcal infection, unspecified

ICD-10 Code A54.6 in Medical Billing and Insurance for Gonococcal infection of anus and rectum

ICD-10 Code A54.6 is crucial in medical billing, particularly in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant symptoms and history to support the diagnosis
• Use A54.6 in conjunction with appropriate CPT codes for services rendered
• Ensure compliance with payer guidelines for accurate reimbursement

Common CPT Pairings: