ICD-10 Code A54.82 | Gonococcal brain abscess Symptoms, Diagnosis, Billing

Gonococcal brain abscess is a rare but serious complication of disseminated gonococcal infection, characterized by the formation of pus-filled cavities in the brain due to Neisseria gonorrhoeae. This condition is clinically significant as it can lead to severe neurological deficits and requires prompt diagnosis and treatment. The ICD-10 Code A54.82 facilitates accurate documentation, billing, and public health reporting, ensuring that healthcare providers can effectively manage and track this infectious disease.

What is ICD-10 Code A54.82 for Gonococcal brain abscess?

ICD-10 Code A54.82 specifically denotes a gonococcal brain abscess, which arises from the spread of Neisseria gonorrhoeae to the central nervous system. This code should be utilized in clinical documentation and billing when a patient presents with neurological symptoms indicative of a brain abscess linked to gonococcal infection, ensuring appropriate treatment and resource allocation.

ICD-10 Code A54.82 – Clinical Definition and Explanation of Gonococcal brain abscess

Gonococcal brain abscess is primarily caused by the hematogenous spread of Neisseria gonorrhoeae, often following untreated or inadequately treated gonorrhea. The condition can progress rapidly, leading to significant morbidity and necessitating immediate medical intervention. Early recognition and treatment are crucial to prevent severe complications.

Key Clinical Features:

• Neurological deficits such as seizures or altered mental status.
• Fever and signs of systemic infection.
• Headache, often severe and persistent.
• Focal neurological signs depending on the abscess location.

ICD-10 Code A54.82 for Gonococcal brain abscess – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code A54.82 is essential for documenting the patient's symptoms, assessment findings, and treatment plans. It plays a critical role in both acute and chronic care settings, ensuring comprehensive patient management and facilitating accurate billing.

What Does ICD-10 Code A54.82 for Gonococcal brain abscess Mean in SOAP Notes?

ICD-10 Code A54.82 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of gonococcal brain abscess. This code is vital for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A54.82 – Gonococcal brain abscess

Gonococcal brain abscess requires urgent medical attention, often necessitating hospitalization for effective management. Appropriate antibiotic therapy is critical to address the underlying infection.

Antibiotic Therapy:

• Ceftriaxone 1-2 g IV every 24 hours for 7-14 days.
• Alternative: Azithromycin 1 g orally as a single dose if ceftriaxone is contraindicated.

Supportive Care:

• Monitor neurological status closely.
• Manage fever and pain with antipyretics and analgesics.
• Consider surgical intervention for abscess drainage if indicated.

Infection Control:

• Implement standard precautions to prevent transmission.
• Educate patients on safe practices to reduce risk of gonococcal infection.

How to Document Symptoms of Gonococcal brain abscess (ICD-10 A54.82) in SOAP Notes

Subjective:

• Patient reports severe headache and confusion.
• History of untreated gonorrhea.
• Complaints of fever and chills.
• Experiencing seizures intermittently.

Objective:

• Neurological examination reveals altered mental status.
• Fever of 39°C (102.2°F) noted.
• CT scan shows a hypodense lesion consistent with abscess.
• Vital signs: BP 110/70 mmHg, HR 100 bpm, RR 22 breaths/min.

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SOAP Note Guidelines for Diagnosing Gonococcal brain abscess (ICD-10 Code A54.82)

Assessment:

• Diagnosis: Gonococcal brain abscess, severe.
• ICD-10 Code: A54.82.
• Contributing factors: History of untreated gonorrhea.
• Neurological deficits present.

Plan:

• Initiate IV ceftriaxone therapy.
• Consult neurosurgery for possible drainage.
• Educate patient on the importance of completing antibiotic therapy.
• Schedule follow-up imaging to assess treatment response.

Treatment & Plan Section for ICD-10 Code A54.82 – Gonococcal brain abscess

• Administer appropriate antibiotics based on sensitivity.
• Provide supportive care including hydration and pain management.
• Monitor neurological status and vital signs regularly.
• Plan for follow-up imaging to evaluate abscess resolution.

Using ICD-10 Code A54.82 for Gonococcal brain abscess in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings.
• Use the code in settings where gonococcal brain abscess is diagnosed.
• Include relevant history of gonorrhea in patient records.
• Align treatment plans with clinical guidelines to support billing.

Related ICD-10 Codes Often Used with Gonococcal brain abscess

• A54.81 – Gonococcal meningitis
• A54.9 – Gonococcal infection, unspecified
• A40.0 – Streptococcal sepsis
• A49.9 – Bacterial infection, unspecified

ICD-10 Code A54.82 in Medical Billing and Insurance for Gonococcal brain abscess

ICD-10 Code A54.82 is crucial for billing in hospital, ER, or infectious disease care settings, ensuring accurate reimbursement for services rendered.

Billing Notes:

• Document all relevant clinical findings and patient history.
• Use the code in conjunction with other relevant diagnoses for comprehensive billing.
• Ensure that treatment plans are clearly outlined in the medical record.
• Include any complications or additional procedures performed.

Common CPT Pairings: