Gonococcal infection, unspecified is a sexually transmitted infection caused by the bacterium Neisseria gonorrhoeae. It is clinically significant due to its potential complications, including pelvic inflammatory disease and infertility. Accurate coding with ICD-10 Code A54.9 facilitates proper diagnosis, documentation, medical billing, and public health reporting, ensuring effective management and treatment of the infection.
What is ICD-10 Code A54.9 for Gonococcal infection, unspecified?
ICD-10 Code A54.9 represents Gonococcal infection, unspecified, indicating an infection caused by Neisseria gonorrhoeae without further specification. This code is used when the clinical presentation does not provide details on the site of infection or complications. It is essential for accurate clinical documentation and billing, particularly in cases where the infection is suspected but not confirmed.
ICD-10 Code A54.9 – Clinical Definition and Explanation of Gonococcal infection, unspecified
Gonococcal infection, unspecified, is primarily caused by the bacterium Neisseria gonorrhoeae, transmitted through sexual contact. The infection can lead to serious health issues if left untreated, necessitating prompt medical attention.
Key Clinical Features:
- Purulent discharge from the genital tract
- Dysuria (painful urination)
- Pelvic pain or discomfort
- Asymptomatic cases are common
ICD-10 Code A54.9 for Gonococcal infection, unspecified – SOAP Notes & Clinical Use
ICD-10 Code A54.9 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans. It is relevant in both acute and chronic care settings, ensuring comprehensive patient management.
What Does ICD-10 Code A54.9 for Gonococcal infection, unspecified Mean in SOAP Notes?
In SOAP notes, ICD-10 Code A54.9 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of gonococcal infection. This code supports continuity of care, facilitates accurate billing, and meets EHR documentation standards.
Treatment Options for ICD-10 Code A54.9 – Gonococcal infection, unspecified
Gonococcal infection requires prompt treatment to prevent complications and transmission. Hospitalization may be necessary in severe cases.
Antibiotic Therapy:
- Ceftriaxone 250 mg IM once
- Azithromycin 1 g orally once
- Doxycycline 100 mg orally twice daily for 7 days (alternative)
Supportive Care:
- Hydration and rest
- Pain management with NSAIDs
- Education on safe sexual practices
Infection Control:
- Notify sexual partners for testing and treatment
- Practice safe sex to prevent transmission
- Follow local public health guidelines during outbreaks
How to Document Symptoms of Gonococcal infection, unspecified (ICD-10 A54.9) in SOAP Notes
Subjective:
- Patient reports dysuria and purulent discharge
- History of unprotected sexual intercourse
- No previous gonococcal infections reported
- Symptoms began 3 days ago
Objective:
- Genital examination reveals purulent discharge
- Positive urine test for Neisseria gonorrhoeae
- Vital signs stable
- No fever or systemic symptoms noted
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SOAP Note Guidelines for Diagnosing Gonococcal infection, unspecified (ICD-10 Code A54.9)
Assessment:
- Diagnosis: Gonococcal infection, unspecified, moderate severity
- ICD-10 Code: A54.9
- Contributing factors: Recent unprotected sexual contact
- Consider differential diagnoses such as chlamydia
Plan:
- Initiate treatment with Ceftriaxone and Azithromycin
- Educate patient on safe sexual practices
- Schedule follow-up in one week to reassess symptoms
- Consider testing for other STIs
Treatment & Plan Section for ICD-10 Code A54.9 – Gonococcal infection, unspecified
- First-line treatment includes Ceftriaxone and Azithromycin
- Educate on the importance of partner notification and treatment
- Monitor for treatment response and potential complications
- Follow-up testing for reinfection or other STIs recommended
Using ICD-10 Code A54.9 for Gonococcal infection, unspecified in Billing & SOAP Note Compliance
- Ensure accurate documentation of symptoms and treatment plans
- Use A54.9 in settings such as outpatient clinics and emergency departments
- 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 Gonococcal infection, unspecified
- A54.0 – Gonococcal infection of the lower genitourinary tract
- A54.1 – Gonococcal infection of the upper genitourinary tract
- A54.2 – Gonococcal infection of the rectum
- A54.3 – Gonococcal infection of the pharynx
- A54.8 – Other gonococcal infections
ICD-10 Code A54.9 in Medical Billing and Insurance for Gonococcal infection, unspecified
ICD-10 Code A54.9 is crucial for billing in hospital, ER, or infectious disease care settings.
Billing Notes:
- Document all patient interactions and treatment plans thoroughly
- Use A54.9 in conjunction with relevant clinical findings
- Ensure compliance with payer requirements for documentation
- Include patient education efforts in billing records
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 87491 | Gonorrhea test, nucleic acid amplification, any source |
| 99213 | Established patient office visit, level 3 |
| 85025 | Complete blood count with automated differential |
| 86592 | Syphilis test, non-treponemal |
Frequently Asked Questions
Common Questions About Using ICD-10 Code A54.9 for Gonococcal infection, unspecified
What are the common symptoms of gonococcal infection?
Common symptoms include dysuria, purulent discharge from the genital tract, and pelvic pain. However, many individuals may be asymptomatic, making regular screening important.
How is gonococcal infection diagnosed?
Diagnosis is typically made through laboratory testing, including nucleic acid amplification tests (NAAT) on urine or genital samples, which detect the presence of Neisseria gonorrhoeae.
What is the treatment for gonococcal infection?
First-line treatment includes a single dose of Ceftriaxone and Azithromycin. Follow-up testing is recommended to ensure the infection has been cleared.
Can gonococcal infection lead to complications?
Yes, untreated gonococcal infections can lead to serious complications such as pelvic inflammatory disease, infertility, and increased susceptibility to HIV.
