ICD-10 Code A54.89 | Other gonococcal infections Symptoms, Diagnosis, Billing

Other gonococcal infections encompass a range of infections caused by Neisseria gonorrhoeae that do not fit into the more specific categories of gonococcal infections. These infections can lead to significant morbidity if left untreated, affecting various anatomical sites. Accurate coding with ICD-10 Code A54.89 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can track and manage these infections effectively.

What is ICD-10 Code A54.89 for Other gonococcal infections?

ICD-10 Code A54.89 represents Other gonococcal infections, which includes infections caused by Neisseria gonorrhoeae that are not classified under specific categories. This code should be used when documenting cases of gonococcal infections that do not have a more specific ICD-10 code, ensuring accurate clinical documentation and appropriate billing practices.

ICD-10 Code A54.89 – Clinical Definition and Explanation of Other gonococcal infections

Other gonococcal infections are caused by the bacterium Neisseria gonorrhoeae, which can infect various mucosal surfaces, including the urogenital tract, rectum, and throat. These infections can lead to serious complications if not treated promptly, necessitating medical attention.

Key Clinical Features:

• Asymptomatic in many cases, especially in females
• Potential for pelvic inflammatory disease (PID) in women
• Increased risk of HIV transmission
• Possible dissemination leading to gonococcal arthritis or dermatitis

ICD-10 Code A54.89 for Other gonococcal infections – SOAP Notes & Clinical Use

ICD-10 Code A54.89 is utilized in SOAP notes to document the presence of other gonococcal infections. It plays a crucial role in capturing patient symptoms, assessment findings, and treatment plans, relevant in both acute and chronic care settings.

What Does ICD-10 Code A54.89 for Other gonococcal infections Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A54.89 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of other gonococcal infections. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code A54.89 – Other gonococcal infections

Prompt treatment of other gonococcal infections is critical to prevent complications. Antibiotic therapy is the mainstay of treatment.

Antibiotic Therapy:

• Ceftriaxone 250 mg IM in a single dose
• Azithromycin 1 g orally in a single dose (alternative)
• Doxycycline 100 mg orally twice daily for 7 days (alternative)

Supportive Care:

• Pain management with NSAIDs as needed
• Hydration and rest to support recovery
• Patient education on safe sexual practices

Infection Control:

• Notify sexual partners for testing and treatment
• Implement safe sex practices to prevent transmission
• Monitor for potential outbreaks in community settings

How to Document Symptoms of Other gonococcal infections (ICD-10 A54.89) in SOAP Notes

Subjective:

• Patient reports dysuria and increased urinary frequency
• History of unprotected sexual intercourse
• Possible exposure to a partner with known gonorrhea

Objective:

• Physical examination reveals purulent urethral discharge
• Cervical examination shows signs of cervicitis
• Laboratory tests confirm Neisseria gonorrhoeae infection

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SOAP Note Guidelines for Diagnosing Other gonococcal infections (ICD-10 Code A54.89)

Assessment:

• Diagnosis: Other gonococcal infections, moderate severity
• ICD-10 Code: A54.89
• Contributing factors: Recent unprotected sexual activity

Plan:

• Initiate treatment with Ceftriaxone 250 mg IM
• Educate patient on safe sexual practices and partner notification
• Schedule follow-up appointment in one week to reassess symptoms

Treatment & Plan Section for ICD-10 Code A54.89 – Other gonococcal infections

• First-line treatment with Ceftriaxone and Azithromycin
• Patient education on the importance of completing the antibiotic course
• Monitoring for treatment response and potential complications
• Follow-up testing for reinfection or treatment failure

Using ICD-10 Code A54.89 for Other gonococcal infections in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings
• Use A54.89 for cases not fitting other gonococcal infection codes
• Align treatment plans with clinical guidelines for justified billing
• Include relevant CPT codes for laboratory tests and consultations

Related ICD-10 Codes Often Used with Other gonococcal infections

• A54.00 – Gonococcal infection of the lower genitourinary tract
• A54.01 – Gonococcal infection of the upper genitourinary tract
• A54.02 – Gonococcal infection of the rectum
• A54.03 – Gonococcal infection of the pharynx
• A54.89 – Other gonococcal infections

ICD-10 Code A54.89 in Medical Billing and Insurance for Other gonococcal infections

ICD-10 Code A54.89 is crucial for billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant patient history and symptoms clearly
• Use A54.89 for cases that do not fit other specific gonococcal codes
• Ensure all chart elements support the ICD-10 claim for compliance

Common CPT Pairings: