ICD-10 Code A54.83 | Gonococcal heart infection Symptoms, Diagnosis, Billing

Gonococcal heart infection is a rare but serious complication of gonorrhea, caused by the bacterium Neisseria gonorrhoeae. This condition can lead to endocarditis or myocarditis, necessitating prompt diagnosis and treatment. Accurate coding with ICD-10 Code A54.83 is essential for effective documentation, billing, and public health reporting, ensuring that healthcare providers can track and manage this infectious disease appropriately.

What is ICD-10 Code A54.83 for Gonococcal heart infection?

ICD-10 Code A54.83 specifically identifies Gonococcal heart infection, a manifestation of disseminated gonococcal infection that affects the heart. This code should be used when documenting cases of endocarditis or myocarditis resulting from Neisseria gonorrhoeae infection, ensuring accurate clinical documentation and appropriate billing for treatment and management.

ICD-10 Code A54.83 – Clinical Definition and Explanation of Gonococcal heart infection

Gonococcal heart infection arises from the systemic spread of Neisseria gonorrhoeae, leading to inflammation of heart tissues. This condition can progress rapidly, requiring immediate medical intervention to prevent severe complications such as heart failure or systemic infection. Early recognition and treatment are crucial.

Key Clinical Features:

• Fever and chills
• Chest pain or discomfort
• Shortness of breath
• Heart murmur or abnormal heart sounds

ICD-10 Code A54.83 for Gonococcal heart infection – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code A54.83 is utilized to document the diagnosis of Gonococcal heart infection, 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 A54.83 for Gonococcal heart infection Mean in SOAP Notes?

ICD-10 Code A54.83 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Gonococcal heart infection. This code is vital for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A54.83 – Gonococcal heart infection

Gonococcal heart infection requires urgent medical attention, often necessitating hospitalization for effective management. Appropriate antibiotic therapy is critical to combat the infection.

Antibiotic Therapy:

• Ceftriaxone 1g IV daily for 7 days
• Azithromycin 1g orally as a single dose
• Alternative: Gentamicin 5mg/kg IV daily for 7 days
• Consideration of dual therapy for resistant strains

Supportive Care:

• Monitoring vital signs and cardiac function
• Fluid management to prevent dehydration
• Pain management as needed
• Patient education on infection prevention

Infection Control:

• Implement standard precautions
• Isolation if necessary during outbreaks
• Educate patients on safe practices to prevent transmission
• Report cases to public health authorities as required

How to Document Symptoms of Gonococcal heart infection (ICD-10 A54.83) in SOAP Notes

Subjective:

• Patient reports fever and chills
• Complains of chest pain worsening with exertion
• Experiences shortness of breath on mild activity
• History of recent gonorrhea infection

Objective:

• Vital signs: elevated temperature, tachycardia
• Auscultation reveals a new heart murmur
• Chest X-ray shows cardiomegaly
• ECG indicates ST-segment changes

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SOAP Note Guidelines for Diagnosing Gonococcal heart infection (ICD-10 Code A54.83)

Assessment:

• Diagnosis: Gonococcal heart infection (A54.83)
• Severity: Moderate to severe based on clinical presentation
• Contributing factors: Recent gonorrhea infection
• Potential complications: Risk of heart failure

Plan:

• Initiate IV antibiotic therapy with ceftriaxone
• Monitor cardiac function and vital signs closely
• Educate patient on the importance of completing antibiotic course
• Schedule follow-up appointment in one week to reassess

Treatment & Plan Section for ICD-10 Code A54.83 – Gonococcal heart infection

• First-line treatment with ceftriaxone or azithromycin
• Patient education on the importance of adherence to treatment
• Regular monitoring of cardiac function and symptoms
• Follow-up care to assess treatment efficacy and prevent recurrence

Using ICD-10 Code A54.83 for Gonococcal heart infection in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings
• Use A54.83 for billing related to gonococcal heart infection treatment
• Align treatment plans with clinical guidelines for justified billing
• Include relevant CPT codes for services rendered

Related ICD-10 Codes Often Used with Gonococcal heart infection

• 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 A54.83 in Medical Billing and Insurance for Gonococcal heart infection

ICD-10 Code A54.83 is crucial for billing in hospital, ER, or infectious disease care settings, ensuring accurate reimbursement for services related to Gonococcal heart infection.

Billing Notes:

• Document all relevant clinical findings and treatment details
• Use A54.83 in conjunction with appropriate CPT codes for billing
• Ensure compliance with payer requirements for documentation
• Maintain thorough records to support claims

Common CPT Pairings: