ICD-10 Code A56.4 | Chlamydial infection of pharynx Symptoms, Diagnosis, Billing

Chlamydial infection of the pharynx is caused by the bacterium Chlamydia trachomatis, primarily transmitted through oral sexual contact. This condition is clinically significant as it can lead to complications such as pharyngitis and may be asymptomatic, complicating diagnosis. The ICD-10 Code A56.4 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring appropriate treatment and tracking of this sexually transmitted infection.

What is ICD-10 Code A56.4 for Chlamydial infection of pharynx?

ICD-10 Code A56.4 specifically represents a chlamydial infection localized in the pharynx. This condition is associated with the sexually transmitted infection caused by Chlamydia trachomatis. The code should be used in clinical documentation and billing when a patient presents with symptoms indicative of a pharyngeal infection, ensuring proper identification and management of the infection.

ICD-10 Code A56.4 – Clinical Definition and Explanation of Chlamydial infection of pharynx

Chlamydial infection of the pharynx is primarily caused by Chlamydia trachomatis, often resulting from oral sexual contact. The infection may progress asymptomatically or present with sore throat and dysphagia, necessitating medical evaluation and treatment to prevent complications. Prompt diagnosis and management are essential to mitigate potential sequelae.

Key Clinical Features:

• Asymptomatic in many cases, complicating diagnosis.
• Symptoms may include sore throat, fever, and lymphadenopathy.
• Increased risk of co-infection with other sexually transmitted infections.
• Potential for complications such as chronic pharyngitis if untreated.

ICD-10 Code A56.4 for Chlamydial infection of pharynx – SOAP Notes & Clinical Use

ICD-10 Code A56.4 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plan for chlamydial infection of the pharynx. This code is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition and facilitating appropriate management.

What Does ICD-10 Code A56.4 for Chlamydial infection of pharynx Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A56.4 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of chlamydial infection of the pharynx. This code is crucial for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A56.4 – Chlamydial infection of pharynx

Chlamydial infection of the pharynx requires prompt treatment to prevent complications and transmission. 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: Erythromycin 500 mg orally four times daily for 7 days.

Supportive Care:

• Analgesics for pain relief.
• Hydration and throat lozenges to soothe irritation.
• Education on safe sexual practices to prevent reinfection.

Infection Control:

• Encourage patients to inform sexual partners for testing and treatment.
• Advise on safe sexual practices to reduce transmission risk.
• Consider public health reporting if indicated.

How to Document Symptoms of Chlamydial infection of pharynx (ICD-10 A56.4) in SOAP Notes

Subjective:

• Patient reports a sore throat for the past week.
• History of recent oral sexual contact.
• Complains of difficulty swallowing.
• No significant fever or systemic symptoms reported.

Objective:

• Throat examination reveals erythema and edema.
• Cervical lymphadenopathy noted on examination.
• No exudate present in the oropharynx.
• Vital signs stable with no fever.

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SOAP Note Guidelines for Diagnosing Chlamydial infection of pharynx (ICD-10 Code A56.4)

Assessment:

• Diagnosis: Chlamydial infection of pharynx, mild severity.
• ICD-10 Code: A56.4.
• Contributing factors: Recent oral sexual contact.
• Consider differential diagnoses such as viral pharyngitis.

Plan:

• Initiate treatment with Azithromycin 1 g orally.
• Provide education 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 A56.4 – Chlamydial infection of pharynx

• 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 appointment to ensure treatment efficacy and partner notification.

Using ICD-10 Code A56.4 for Chlamydial infection of pharynx in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and history in Subjective (S) and Objective (O) sections.
• Use the code in conjunction with appropriate CPT codes for testing and treatment.
• Document patient education and follow-up plans to support billing.
• Align treatment plans with clinical guidelines to justify coding.

Related ICD-10 Codes Often Used with Chlamydial infection of pharynx

• A56.0 – Chlamydial infection of lower genitourinary tract
• A56.1 – Chlamydial infection of cervix
• A56.2 – Chlamydial infection of rectum
• A56.3 – Chlamydial infection of urethra

ICD-10 Code A56.4 in Medical Billing and Insurance for Chlamydial infection of pharynx

ICD-10 Code A56.4 is essential for accurate billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant patient history and symptoms to support the use of this code.
• Use in conjunction with appropriate CPT codes for diagnostic tests and treatments.
• Ensure compliance with payer requirements for documentation and coding.
• Review coding guidelines regularly to stay updated on best practices.

Common CPT Pairings: