ICD-10 Code A56.2 | Chlamydial infection of genitourinary tract, unspecified Symptoms, Diagnosis, Billing

Chlamydial infection of the genitourinary tract, unspecified, is caused by the bacterium Chlamydia trachomatis. This sexually transmitted infection can lead to serious reproductive health issues if left untreated, including pelvic inflammatory disease and infertility. The ICD-10 Code A56.2 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 A56.2 for Chlamydial infection of genitourinary tract, unspecified?

ICD-10 Code A56.2 represents a chlamydial infection of the genitourinary tract that is unspecified. This code is used when the specific site of infection is not documented or when the infection is not further classified. It is essential for clinical documentation and billing when diagnosing patients with chlamydia, ensuring appropriate treatment and follow-up care.

ICD-10 Code A56.2 – Clinical Definition and Explanation of Chlamydial infection of genitourinary tract, unspecified

Chlamydial infection of the genitourinary tract, unspecified, is primarily caused by Chlamydia trachomatis, a common sexually transmitted pathogen. The infection can progress asymptomatically, leading to severe complications if not treated. Medical attention is crucial to prevent long-term reproductive health issues.

Key Clinical Features:

• Often asymptomatic, especially in women.
• Symptoms may include abnormal discharge, dysuria, and pelvic pain.
• Can lead to complications such as pelvic inflammatory disease (PID) and infertility.
• Higher prevalence in sexually active young adults.

ICD-10 Code A56.2 for Chlamydial infection of genitourinary tract, unspecified – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code A56.2 is utilized to document the presence of chlamydial infection, aiding in the assessment of symptoms, diagnosis, and treatment plans. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management.

What Does ICD-10 Code A56.2 for Chlamydial infection of genitourinary tract, unspecified Mean in SOAP Notes?

ICD-10 Code A56.2 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of chlamydial infection. This code is vital for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A56.2 – Chlamydial infection of genitourinary tract, unspecified

Chlamydial infections require prompt treatment to prevent complications. Hospitalization may be necessary in severe cases, and appropriate antibiotic therapy is essential.

Antibiotic Therapy:

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

Supportive Care:

• Encourage hydration and rest.
• Provide education on safe sexual practices.
• Monitor for symptoms of complications.

Infection Control:

• Advise patients to inform sexual partners.
• Recommend abstaining from sexual activity until treatment is completed.
• Implement routine screening in high-risk populations.

How to Document Symptoms of Chlamydial infection of genitourinary tract, unspecified (ICD-10 A56.2) in SOAP Notes

Subjective:

• Patient reports dysuria and abnormal vaginal discharge.
• History of unprotected sexual intercourse.
• No previous diagnosis of sexually transmitted infections.
• Reports pelvic pain during menstruation.

Objective:

• Physical examination reveals cervical tenderness.
• Lab results show positive chlamydia test.
• Vital signs within normal limits.
• No signs of acute abdomen on examination.

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SOAP Note Guidelines for Diagnosing Chlamydial infection of genitourinary tract, unspecified (ICD-10 Code A56.2)

Assessment:

• Diagnosis: Chlamydial infection of genitourinary tract, unspecified (ICD-10 A56.2).
• Severity: Mild, with no acute complications noted.
• Contributing factors: Recent unprotected sexual activity.
• Consider differential diagnoses such as urinary tract infection.

Plan:

• Initiate treatment with Azithromycin 1 g orally.
• Educate patient on safe sexual practices and the importance of partner notification.
• Schedule follow-up appointment in one week to reassess symptoms.
• Consider retesting for STIs in three months.

Treatment & Plan Section for ICD-10 Code A56.2 – Chlamydial infection of genitourinary tract, unspecified

• First-line treatment: Azithromycin or Doxycycline.
• Non-pharmacologic strategies: Safe sex education and partner notification.
• Monitoring: Follow-up testing for reinfection and symptom resolution.
• Follow-up practices: Schedule reassessment within one week.

Using ICD-10 Code A56.2 for Chlamydial infection of genitourinary tract, unspecified in Billing & SOAP Note Compliance

• Select appropriate code based on clinical findings and documentation.
• Ensure Subjective (S) and Objective (O) sections clearly reflect symptoms and diagnosis.
• Align treatment plans with clinical guidelines to support justified billing.
• Document any relevant CPT codes for services rendered.

Related ICD-10 Codes Often Used with Chlamydial infection of genitourinary tract, unspecified

• A56.0 – Chlamydial infection of the lower genitourinary tract
• A56.1 – Chlamydial infection of the upper genitourinary tract
• A54.9 – Gonococcal infection, unspecified

ICD-10 Code A56.2 in Medical Billing and Insurance for Chlamydial infection of genitourinary tract, unspecified

ICD-10 Code A56.2 is crucial for accurate billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant patient history and clinical findings to support the diagnosis.
• Use this code in conjunction with appropriate CPT codes for laboratory tests and consultations.
• Ensure compliance with payer guidelines for coding and documentation.
• Review coding updates regularly to maintain accuracy.

Common CPT Pairings: