ICD-10 Code A56.3 | Chlamydial infection of anus and rectum Symptoms, Diagnosis, Billing

Chlamydial infection of the anus and rectum is caused by the bacterium Chlamydia trachomatis. This sexually transmitted infection can lead to significant morbidity if left untreated, including complications such as proctitis and increased susceptibility to HIV. The ICD-10 Code A56.3 facilitates accurate diagnosis, documentation, and billing, ensuring proper public health reporting and management of this condition.

What is ICD-10 Code A56.3 for Chlamydial infection of anus and rectum?

ICD-10 Code A56.3 specifically denotes a chlamydial infection localized to the anus and rectum. This condition is often asymptomatic but can present with symptoms such as rectal pain, discharge, and bleeding. This code should be used in clinical documentation and billing when a patient is diagnosed with this infection, ensuring appropriate treatment and follow-up.

ICD-10 Code A56.3 – Clinical Definition and Explanation of Chlamydial infection of anus and rectum

Chlamydial infection of the anus and rectum is primarily caused by Chlamydia trachomatis, typically transmitted through sexual contact. The infection can progress asymptomatically, leading to severe complications if untreated. Medical attention is crucial for diagnosis and management to prevent long-term health issues.

Key Clinical Features:

• Asymptomatic in many cases, but may present with rectal pain or discomfort.
• Possible discharge from the rectum, which may be purulent.
• Symptoms may mimic other gastrointestinal conditions, complicating diagnosis.
• Increased risk of co-infection with other sexually transmitted infections.

ICD-10 Code A56.3 for Chlamydial infection of anus and rectum – SOAP Notes & Clinical Use

ICD-10 Code A56.3 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plan. It is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition and guiding appropriate management.

What Does ICD-10 Code A56.3 for Chlamydial infection of anus and rectum Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A56.3 connects subjective patient-reported symptoms with objective clinical findings, leading to a formal diagnosis. This code supports continuity of care, facilitates accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code A56.3 – Chlamydial infection of anus and rectum

Chlamydial infection of the anus and rectum requires prompt treatment to prevent complications. Antibiotic therapy is the mainstay of treatment.

Antibiotic Therapy:

• Azithromycin 1 g orally in a single dose.
• Doxycycline 100 mg orally twice daily for 7 days.
• Alternative: Ofloxacin 300 mg orally twice daily for 7 days.

Supportive Care:

• Pain management with NSAIDs as needed.
• Patient education on safe sexual practices.
• Follow-up testing to ensure resolution of infection.

Infection Control:

• Advise patients to inform sexual partners for testing and treatment.
• Encourage condom use to prevent transmission.
• Implement screening programs in high-risk populations.

How to Document Symptoms of Chlamydial infection of anus and rectum (ICD-10 A56.3) in SOAP Notes

Subjective:

• Patient reports rectal pain and discomfort.
• History of unprotected sexual intercourse.
• Possible rectal discharge noted by the patient.
• No previous history of similar symptoms.

Objective:

• Rectal examination reveals tenderness.
• Purulent discharge observed upon examination.
• No fever or systemic signs of infection.
• Negative results for other STIs on initial screening.

Secure, compliant, and built for trust

HIPAA-compliant and designed with privacy in mind, your patient’s data is protected. Focus on care while we safeguard your information.

Learn more

SOAP Note Guidelines for Diagnosing Chlamydial infection of anus and rectum (ICD-10 Code A56.3)

Assessment:

• Diagnosis: Chlamydial infection of anus and rectum, mild severity.
• ICD-10 Code: A56.3.
• Contributing factors: Recent unprotected sexual contact.
• Consider differential diagnoses such as other STIs.

Plan:

• Initiate treatment with Azithromycin 1 g orally.
• Educate patient on safe sexual practices and follow-up care.
• Schedule follow-up appointment in 1 week for reassessment.
• Consider testing for other STIs.

Treatment & Plan Section for ICD-10 Code A56.3 – Chlamydial infection of anus and rectum

• 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 A56.3 for Chlamydial infection of anus and rectum in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings.
• 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 provided during the visit.

Related ICD-10 Codes Often Used with Chlamydial infection of anus and rectum

• A56.0 – Chlamydial infection of lower genitourinary tract
• A56.1 – Chlamydial infection of cervix
• A56.2 – Chlamydial infection of urethra
• A56.4 – Chlamydial infection of other sites

ICD-10 Code A56.3 in Medical Billing and Insurance for Chlamydial infection of anus and rectum

ICD-10 Code A56.3 is critical 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 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: