ICD-10 Code A56.01 | Chlamydial cystitis and urethritis Symptoms, Diagnosis, Billing

Chlamydial cystitis and urethritis is an infection caused by the bacterium Chlamydia trachomatis, leading to inflammation of the bladder and urethra. This condition is clinically significant due to its potential complications, including pelvic inflammatory disease and infertility. Accurate coding with ICD-10 Code A56.01 facilitates proper diagnosis, documentation, medical billing, and public health reporting, ensuring effective management and treatment of affected patients.

What is ICD-10 Code A56.01 for Chlamydial cystitis and urethritis?

ICD-10 Code A56.01 specifically denotes chlamydial cystitis and urethritis, which are inflammatory conditions of the urinary tract caused by Chlamydia trachomatis. This code should be utilized in clinical documentation and billing when a patient presents with symptoms such as dysuria, increased urinary frequency, and pelvic pain, confirming the diagnosis of this sexually transmitted infection.

ICD-10 Code A56.01 – Clinical Definition and Explanation of Chlamydial cystitis and urethritis

Chlamydial cystitis and urethritis is primarily caused by the sexually transmitted bacterium Chlamydia trachomatis. The infection can lead to significant morbidity if left untreated, including complications such as infertility and chronic pelvic pain. Prompt medical attention is essential for effective management.

Key Clinical Features:

• Dysuria (painful urination)
• Increased urinary frequency and urgency
• Pelvic or lower abdominal pain
• Possible discharge from the urethra

ICD-10 Code A56.01 for Chlamydial cystitis and urethritis – SOAP Notes & Clinical Use

ICD-10 Code A56.01 is integral in SOAP notes for documenting the patient's symptoms, assessment findings, and treatment plans. It is relevant in both acute and chronic care settings, ensuring comprehensive patient management and accurate billing.

What Does ICD-10 Code A56.01 for Chlamydial cystitis and urethritis Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A56.01 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of chlamydial cystitis and urethritis. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code A56.01 – Chlamydial cystitis and urethritis

Chlamydial cystitis and urethritis requires prompt treatment to prevent complications. Antibiotic therapy is the cornerstone of management.

Antibiotic Therapy:

• Azithromycin 1 g orally in a single dose
• Doxycycline 100 mg orally twice daily for 7 days
• Alternative: Levofloxacin 500 mg orally once daily for 7 days

Supportive Care:

• Increased fluid intake to promote urinary flow
• Pain management with NSAIDs as needed
• Patient education on safe sexual practices

Infection Control:

• Encourage testing and treatment of sexual partners
• Advise on safe sex practices to prevent reinfection
• Report cases to public health authorities as required

How to Document Symptoms of Chlamydial cystitis and urethritis (ICD-10 A56.01) in SOAP Notes

Subjective:

• Patient reports dysuria and increased urinary frequency.
• History of unprotected sexual intercourse.
• Complaints of pelvic pain and possible discharge.

Objective:

• Physical examination reveals tenderness in the suprapubic area.
• Urinalysis shows leukocytes and nitrites.
• Positive nucleic acid amplification test (NAAT) for Chlamydia.

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SOAP Note Guidelines for Diagnosing Chlamydial cystitis and urethritis (ICD-10 Code A56.01)

Assessment:

• Diagnosis: Chlamydial cystitis and urethritis, mild severity.
• ICD-10 Code: A56.01.
• Contributing factors: Recent unprotected sexual activity.

Plan:

• Initiate treatment with Azithromycin 1 g orally.
• Educate patient on safe sexual practices and partner notification.
• Schedule follow-up in one week to reassess symptoms.

Treatment & Plan Section for ICD-10 Code A56.01 – Chlamydial cystitis and urethritis

• First-line treatment with Azithromycin or Doxycycline.
• Encourage hydration and symptom management.
• Monitor for resolution of symptoms and potential complications.
• Follow-up testing for reinfection or treatment failure.

Using ICD-10 Code A56.01 for Chlamydial cystitis and urethritis in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and treatment in SOAP notes.
• Use A56.01 in appropriate clinical settings, including outpatient and emergency care.
• Align treatment plans with clinical guidelines to support justified billing.
• Document patient education and follow-up plans clearly.

Related ICD-10 Codes Often Used with Chlamydial cystitis and urethritis

• A56.00 – Chlamydial infection of unspecified site
• A56.02 – Chlamydial urethritis
• N30.00 – Acute cystitis, unspecified
• N34.0 – Urethritis, not elsewhere classified

ICD-10 Code A56.01 in Medical Billing and Insurance for Chlamydial cystitis and urethritis

ICD-10 Code A56.01 is crucial for billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant patient history and symptoms to support the claim.
• Use A56.01 in conjunction with appropriate CPT codes for services rendered.
• Ensure compliance with payer-specific documentation requirements.

Common CPT Pairings: