ICD-10 Code A54.84 | Gonococcal pneumonia Symptoms, Diagnosis, Billing

Gonococcal pneumonia is a rare but serious respiratory infection caused by the bacterium Neisseria gonorrhoeae. It primarily affects infants born to infected mothers but can also occur in adults, particularly those with compromised immune systems. Accurate coding with ICD-10 Code A54.84 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can track and manage this infectious disease effectively.

What is ICD-10 Code A54.84 for Gonococcal pneumonia?

ICD-10 Code A54.84 specifically represents Gonococcal pneumonia, an infection of the lungs caused by Neisseria gonorrhoeae. This code should be used when documenting cases of pneumonia linked to gonococcal infection, particularly in patients with a history of gonorrhea or in newborns exposed during delivery. Accurate use of this code is crucial for clinical documentation and billing processes.

ICD-10 Code A54.84 – Clinical Definition and Explanation of Gonococcal pneumonia

Gonococcal pneumonia is primarily caused by the bacterium Neisseria gonorrhoeae, which can lead to severe respiratory symptoms. The condition often arises in newborns from infected mothers during childbirth but can also affect adults, particularly those with underlying health issues. Prompt medical attention is necessary to prevent complications.

Key Clinical Features:

• Cough, often productive with purulent sputum
• Fever and chills indicating systemic infection
• Chest pain or discomfort, especially during breathing
• Respiratory distress or difficulty breathing

ICD-10 Code A54.84 for Gonococcal pneumonia – SOAP Notes & Clinical Use

ICD-10 Code A54.84 is utilized in SOAP notes to document the clinical presentation, assessment, and treatment of Gonococcal pneumonia. This code aids in capturing the patient's symptoms, guiding the clinical assessment, and formulating an appropriate treatment plan, relevant in both acute and chronic care settings.

What Does ICD-10 Code A54.84 for Gonococcal pneumonia Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A54.84 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Gonococcal pneumonia. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code A54.84 – Gonococcal pneumonia

Gonococcal pneumonia requires urgent medical intervention, often necessitating hospitalization for effective management. Appropriate antibiotic therapy is critical to address the infection.

Antibiotic Therapy:

• Ceftriaxone 1g IV or IM once, or
• Cefotaxime 1g IV every 8 hours for 7 days, or
• Azithromycin 1g orally once as an alternative

Supportive Care:

• Oxygen therapy to manage hypoxia
• Intravenous fluids to maintain hydration
• Monitoring of vital signs and respiratory status

Infection Control:

• Implement standard precautions to prevent transmission
• Isolate infected patients if necessary
• Educate staff on infection control measures

How to Document Symptoms of Gonococcal pneumonia (ICD-10 A54.84) in SOAP Notes

Subjective:

• Patient reports persistent cough with greenish sputum
• History of recent fever and chills
• Complaints of chest pain during deep breaths
• Shortness of breath worsening over the past few days

Objective:

• Auscultation reveals crackles and wheezing
• Respiratory rate of 28 breaths per minute
• Oxygen saturation at 90% on room air
• Fever of 101°F noted on examination

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SOAP Note Guidelines for Diagnosing Gonococcal pneumonia (ICD-10 Code A54.84)

Assessment:

• Diagnosis: Gonococcal pneumonia, moderate severity
• ICD-10 Code: A54.84
• Contributing factors: Recent history of gonorrhea
• Potential complications: Risk of respiratory failure

Plan:

• Initiate ceftriaxone 1g IV daily for 7 days
• Provide supplemental oxygen as needed
• Educate patient on the importance of completing antibiotic therapy
• Schedule follow-up in 1 week to reassess respiratory status

Treatment & Plan Section for ICD-10 Code A54.84 – Gonococcal pneumonia

• First-line treatment includes ceftriaxone or cefotaxime.
• Supportive care involves oxygen therapy and hydration.
• Monitor respiratory status and vital signs closely.
• Educate patients on the importance of adherence to treatment.

Using ICD-10 Code A54.84 for Gonococcal pneumonia in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and history in SOAP notes.
• Use the code in settings where gonococcal pneumonia is diagnosed.
• 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 pneumonia

• A54.9 – Gonococcal infection, unspecified
• J20.9 – Acute bronchitis, unspecified
• J18.9 – Pneumonia, unspecified organism
• A54.81 – Gonococcal pharyngitis

ICD-10 Code A54.84 in Medical Billing and Insurance for Gonococcal pneumonia

ICD-10 Code A54.84 is critical in billing for hospitalizations and outpatient visits related to Gonococcal pneumonia.

Billing Notes:

• Document all relevant clinical findings to support the diagnosis.
• Use the code in emergency and infectious disease care settings.
• Ensure that the patient's history of gonorrhea is clearly noted.
• Include all pertinent symptoms in the documentation.

Common CPT Pairings: