ICD-10 Code A54.86 | Gonococcal sepsis Symptoms, Diagnosis, Billing

Gonococcal sepsis is a severe systemic infection caused by the bacterium Neisseria gonorrhoeae. It is characterized by the presence of gonococci in the bloodstream, leading to a range of clinical manifestations including fever, chills, and septic shock. Accurate coding with ICD-10 Code A54.86 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and treat this serious condition.

What is ICD-10 Code A54.86 for Gonococcal sepsis?

ICD-10 Code A54.86 represents Gonococcal sepsis, a life-threatening condition resulting from the dissemination of Neisseria gonorrhoeae into the bloodstream. This code should be used in clinical documentation and billing when a patient presents with systemic symptoms indicative of sepsis related to gonococcal infection, ensuring accurate representation of the patient's condition for treatment and reimbursement purposes.

ICD-10 Code A54.86 – Clinical Definition and Explanation of Gonococcal sepsis

Gonococcal sepsis is primarily caused by the bacterium Neisseria gonorrhoeae, which can enter the bloodstream following an untreated gonococcal infection. The condition can progress rapidly, leading to severe systemic symptoms and requiring immediate medical intervention. Prompt recognition and treatment are crucial to prevent complications and improve patient outcomes.

Key Clinical Features:

• Fever and chills
• Severe joint pain or swelling
• Skin lesions or rash
• Signs of septic shock

ICD-10 Code A54.86 for Gonococcal sepsis – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code A54.86 is utilized to document the diagnosis of Gonococcal sepsis, capturing the patient's symptoms, clinical assessment, and treatment plan. This code is relevant in both acute and chronic care settings, facilitating effective communication among healthcare providers and ensuring comprehensive patient care.

What Does ICD-10 Code A54.86 for Gonococcal sepsis Mean in SOAP Notes?

ICD-10 Code A54.86 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Gonococcal sepsis. This code plays a vital role in ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A54.86 – Gonococcal sepsis

Gonococcal sepsis is a medical emergency that often necessitates hospitalization for effective management. Appropriate antibiotic therapy is critical in treating the infection and preventing complications.

Antibiotic Therapy:

• Ceftriaxone 1g IV every 24 hours for 7 days
• Azithromycin 1g orally as a single dose
• Alternative: Gentamicin 5mg/kg IV once daily for 7 days
• Consideration of dual therapy based on resistance patterns

Supportive Care:

• Intravenous fluids to maintain hydration
• Monitoring vital signs and organ function
• Pain management as needed
• Nutritional support if indicated

Infection Control:

• Isolation precautions to prevent transmission
• Education on safe practices to reduce risk of reinfection
• Notification of public health authorities if indicated
• Screening and treatment of sexual partners

How to Document Symptoms of Gonococcal sepsis (ICD-10 A54.86) in SOAP Notes

Subjective:

• Patient reports fever and chills for 3 days
• Complains of severe joint pain in knees
• Noticed a rash on the trunk and extremities
• History of untreated gonorrhea

Objective:

• Temperature 102°F
• Heart rate 110 bpm
• Blood pressure 90/60 mmHg
• Joint swelling noted on examination

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SOAP Note Guidelines for Diagnosing Gonococcal sepsis (ICD-10 Code A54.86)

Assessment:

• Diagnosis: Gonococcal sepsis, severe
• ICD-10 Code: A54.86
• Contributing factors: Untreated gonorrhea, possible immunocompromised state
• Severity: High risk for septic shock

Plan:

• Initiate IV ceftriaxone 1g daily
• Administer IV fluids for hydration
• Monitor vital signs every hour
• Educate patient on the importance of follow-up and partner notification

Treatment & Plan Section for ICD-10 Code A54.86 – Gonococcal sepsis

• First-line treatment with ceftriaxone and azithromycin
• Supportive care including hydration and monitoring
• Patient education on infection prevention
• Follow-up appointments to assess treatment response

Using ICD-10 Code A54.86 for Gonococcal sepsis in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings in SOAP notes
• Use the code in acute care settings for appropriate reimbursement
• Align treatment plans with clinical guidelines to support billing
• Document any complications or comorbidities that may affect care

Related ICD-10 Codes Often Used with Gonococcal sepsis

• A54.00 – Gonococcal infection of unspecified site
• A54.01 – Gonococcal infection of the urethra
• A54.02 – Gonococcal infection of the cervix
• A54.03 – Gonococcal infection of the rectum

ICD-10 Code A54.86 in Medical Billing and Insurance for Gonococcal sepsis

ICD-10 Code A54.86 is crucial in medical billing, particularly 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 appropriate CPT codes for services rendered
• Ensure compliance with payer guidelines for documentation
• Review coding updates regularly to maintain accuracy

Common CPT Pairings: