Chlamydial female pelvic inflammatory disease is an infection of the female reproductive organs caused by the bacterium Chlamydia trachomatis. It is clinically significant due to its potential to cause severe complications such as infertility, ectopic pregnancy, and chronic pelvic pain. The ICD-10 Code A56.11 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and treat this condition.
What is ICD-10 Code A56.11 for Chlamydial female pelvic inflammatory disease?
ICD-10 Code A56.11 specifically represents Chlamydial female pelvic inflammatory disease, a serious infection that can arise from untreated chlamydia. This code should be used in clinical documentation and billing when a patient presents with symptoms indicative of pelvic inflammatory disease linked to chlamydia, ensuring proper identification and management of the condition.
ICD-10 Code A56.11 – Clinical Definition and Explanation of Chlamydial female pelvic inflammatory disease
Chlamydial female pelvic inflammatory disease is primarily caused by the sexually transmitted infection chlamydia. If left untreated, it can lead to significant reproductive health issues. Prompt medical attention is crucial to prevent complications such as infertility and chronic pain.
Key Clinical Features:
- Lower abdominal pain or tenderness
- Abnormal vaginal discharge
- Fever and chills
- Pain during intercourse
ICD-10 Code A56.11 for Chlamydial female pelvic inflammatory disease – SOAP Notes & Clinical Use
In SOAP notes, ICD-10 Code A56.11 is utilized to document the patient's symptoms, assessment findings, and treatment plans. This code is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition.
What Does ICD-10 Code A56.11 for Chlamydial female pelvic inflammatory disease Mean in SOAP Notes?
ICD-10 Code A56.11 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of chlamydial female pelvic inflammatory disease. This code is essential for ensuring continuity of care, supporting billing processes, and meeting EHR documentation standards.
Treatment Options for ICD-10 Code A56.11 – Chlamydial female pelvic inflammatory disease
Chlamydial female pelvic inflammatory disease requires prompt treatment to prevent complications. Hospitalization may be necessary in severe cases.
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:
- Pain management with NSAIDs
- Hydration and rest
- Education on safe sexual practices
Infection Control:
- Screening and treatment of sexual partners
- Counseling on prevention of sexually transmitted infections
- Follow-up testing to ensure resolution of infection
How to Document Symptoms of Chlamydial female pelvic inflammatory disease (ICD-10 A56.11) in SOAP Notes
Subjective:
- Patient reports lower abdominal pain
- Complains of abnormal vaginal discharge
- Experiences pain during intercourse
- Reports fever and chills
Objective:
- Tenderness on pelvic examination
- Fever of 101°F
- Abnormal vaginal discharge noted
- Positive cervical motion tenderness
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SOAP Note Guidelines for Diagnosing Chlamydial female pelvic inflammatory disease (ICD-10 Code A56.11)
Assessment:
- Diagnosis: Chlamydial female pelvic inflammatory disease, moderate severity
- ICD-10 Code: A56.11
- Contributing factors: Recent unprotected sexual intercourse
- Possible complications: Risk of infertility
Plan:
- Initiate antibiotic therapy as per guidelines
- Educate patient on safe sexual practices
- Schedule follow-up appointment in one week
- Consider referral to a specialist if symptoms persist
Treatment & Plan Section for ICD-10 Code A56.11 – Chlamydial female pelvic inflammatory disease
- First-line treatment with azithromycin or doxycycline
- Patient education on the importance of completing the antibiotic course
- Monitoring for symptom resolution and potential complications
- Follow-up testing for reinfection or treatment failure
Using ICD-10 Code A56.11 for Chlamydial female pelvic inflammatory disease in Billing & SOAP Note Compliance
- Ensure accurate documentation of symptoms and clinical findings in SOAP notes
- Use the code in appropriate clinical settings, including outpatient and inpatient care
- Align treatment plans with clinical guidelines to support justified billing
- Document any relevant patient education and follow-up plans
Related ICD-10 Codes Often Used with Chlamydial female pelvic inflammatory disease
- A56.00 – Chlamydial infection of unspecified site
- A56.9 – Chlamydial infection, unspecified
- N70.0 – Acute salpingitis
- N73.9 – Female pelvic inflammatory disease, unspecified
ICD-10 Code A56.11 in Medical Billing and Insurance for Chlamydial female pelvic inflammatory disease
ICD-10 Code A56.11 is crucial for billing in hospital, ER, or infectious disease care settings.
Billing Notes:
- Document all relevant patient history and clinical findings to support the claim
- Use the code in conjunction with appropriate CPT codes for services rendered
- Ensure compliance with payer guidelines for documentation and coding
- Review coding updates regularly to maintain accuracy
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 99213 | Established patient office visit, level 3 |
| 87591 | Chlamydia trachomatis, amplified probe technique |
| 99285 | Emergency department visit, high severity |
Frequently Asked Questions
Common Questions About Using ICD-10 Code A56.11 for Chlamydial female pelvic inflammatory disease
What are the common symptoms of chlamydial female pelvic inflammatory disease?
Common symptoms include lower abdominal pain, abnormal vaginal discharge, fever, and pain during intercourse. Early recognition and treatment are essential to prevent complications.
How is chlamydial female pelvic inflammatory disease diagnosed?
Diagnosis typically involves a pelvic examination, patient history, and laboratory tests to detect Chlamydia trachomatis. The use of ICD-10 Code A56.11 is crucial for accurate documentation.
What is the treatment for chlamydial female pelvic inflammatory disease?
Treatment usually involves antibiotics such as azithromycin or doxycycline. Supportive care and education on safe sexual practices are also important components of management.
Why is it important to document using ICD-10 Code A56.11?
Accurate documentation using ICD-10 Code A56.11 ensures proper billing, continuity of care, and compliance with healthcare regulations, facilitating effective management of the condition.
