ICD-10 Code A54.81 | Gonococcal meningitis Symptoms, Diagnosis, Billing

Gonococcal meningitis is a severe infection of the protective membranes covering the brain and spinal cord, caused by Neisseria gonorrhoeae. This condition is clinically significant due to its potential for serious complications, including neurological damage and systemic infection. The ICD-10 Code A54.81 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 A54.81 for Gonococcal meningitis?

ICD-10 Code A54.81 specifically represents Gonococcal meningitis, an infection resulting from the spread of Neisseria gonorrhoeae to the central nervous system. This code should be used in clinical documentation and billing when a patient presents with symptoms indicative of meningitis, particularly in the context of a confirmed or suspected gonococcal infection.

ICD-10 Code A54.81 – Clinical Definition and Explanation of Gonococcal meningitis

Gonococcal meningitis is primarily caused by the bacterium Neisseria gonorrhoeae, which can enter the bloodstream and subsequently infect the meninges. This condition requires immediate medical attention due to its rapid progression and potential for severe complications, including death. Early diagnosis and treatment are crucial for favorable outcomes.

Key Clinical Features:

• Fever and chills
• Severe headache and neck stiffness
• Altered mental status or confusion
• Photophobia and nausea

ICD-10 Code A54.81 for Gonococcal meningitis – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code A54.81 is utilized to document the diagnosis of Gonococcal meningitis, 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 A54.81 for Gonococcal meningitis Mean in SOAP Notes?

ICD-10 Code A54.81 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Gonococcal meningitis. This code is essential for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A54.81 – Gonococcal meningitis

Gonococcal meningitis is a medical emergency that often necessitates hospitalization for prompt treatment. Appropriate antibiotic therapy is critical to manage the infection effectively.

Antibiotic Therapy:

• Ceftriaxone 1-2 g IV daily for 7-14 days
• Alternative: Azithromycin 1 g orally in a single dose

Supportive Care:

• Intravenous fluids to maintain hydration
• Pain management with analgesics
• Monitoring for neurological complications

Infection Control:

• Implement standard precautions to prevent transmission
• Notify public health authorities in case of outbreaks
• Educate patients on safe practices to reduce risk of infection

How to Document Symptoms of Gonococcal meningitis (ICD-10 A54.81) in SOAP Notes

Subjective:

• Patient reports severe headache and neck stiffness.
• Complains of fever and chills for the past two days.
• States experiencing nausea and sensitivity to light.
• History of recent gonococcal infection.

Objective:

• Vital signs: Temperature 102°F, pulse 110 bpm.
• Physical exam reveals nuchal rigidity.
• Neurological exam shows confusion and disorientation.
• Lumbar puncture indicates elevated white blood cell count.

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SOAP Note Guidelines for Diagnosing Gonococcal meningitis (ICD-10 Code A54.81)

Assessment:

• Diagnosis: Gonococcal meningitis, severe.
• ICD-10 Code: A54.81.
• Contributing factors: Recent history of gonorrhea.
• Severity: High risk for complications.

Plan:

• Initiate IV ceftriaxone therapy.
• Provide supportive care including hydration and pain management.
• Monitor neurological status closely.
• Schedule follow-up lumbar puncture to assess treatment response.

Treatment & Plan Section for ICD-10 Code A54.81 – Gonococcal meningitis

• Administer first-line antibiotics as per guidelines.
• Educate patient on the importance of completing the antibiotic course.
• Monitor for signs of complications such as seizures or persistent fever.
• Arrange for follow-up appointments to ensure resolution of infection.

Using ICD-10 Code A54.81 for Gonococcal meningitis in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings.
• Use the code in settings where gonococcal meningitis is diagnosed or treated.
• Align treatment plans with clinical guidelines to support billing.
• Include relevant history of gonococcal infection in documentation.

Related ICD-10 Codes Often Used with Gonococcal meningitis

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

ICD-10 Code A54.81 in Medical Billing and Insurance for Gonococcal meningitis

ICD-10 Code A54.81 is crucial for billing in hospital, emergency room, or infectious disease care settings.

Billing Notes:

• Document all relevant clinical findings to support the diagnosis.
• Use the code in conjunction with other related codes as necessary.
• Ensure compliance with payer requirements for documentation.
• Include patient history of gonorrhea to justify the diagnosis.

Common CPT Pairings: