ICD-10 Code A58 | Granuloma inguinale Symptoms, Diagnosis, Billing

Granuloma inguinale is a chronic, progressive granulomatous infection caused by the bacterium Calymmatobacterium granulomatis. It primarily affects the genital and perianal regions, leading to ulcerative lesions. Accurate coding with ICD-10 Code A58 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and track this condition.

What is ICD-10 Code A58 for Granuloma inguinale?

ICD-10 Code A58 represents Granuloma inguinale, a sexually transmitted infection characterized by the formation of painless, beefy-red ulcers. This code should be used in clinical documentation when diagnosing patients with this condition, facilitating appropriate treatment and billing processes while ensuring accurate health records.

ICD-10 Code A58 – Clinical Definition and Explanation of Granuloma inguinale

Granuloma inguinale is caused by the bacterium Calymmatobacterium granulomatis, leading to the development of painless ulcers in the genital area. The condition can progress if left untreated, resulting in significant morbidity. Prompt medical attention is necessary to prevent complications and transmission.

Key Clinical Features:

• Painless, beefy-red ulcers in the genital or perianal region.
• Ulcers may bleed easily and can become extensive if untreated.
• Associated with sexual activity and more prevalent in certain geographic areas.
• May present with secondary bacterial infections.

ICD-10 Code A58 for Granuloma inguinale – SOAP Notes & Clinical Use

ICD-10 Code A58 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans. It is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition and facilitating appropriate billing.

What Does ICD-10 Code A58 for Granuloma inguinale Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A58 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Granuloma inguinale. This code is crucial for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A58 – Granuloma inguinale

Granuloma inguinale requires prompt treatment to prevent complications and further transmission. Antibiotic therapy is the primary treatment approach.

Antibiotic Therapy:

• Azithromycin 1g orally once weekly for 3 weeks.
• Doxycycline 100 mg orally twice daily for 3 weeks.
• Ciprofloxacin 500 mg orally twice daily for 3 weeks.
• Alternative options include Trimethoprim-sulfamethoxazole.

Supportive Care:

• Regular cleaning of ulcerated areas to prevent secondary infections.
• Pain management with analgesics as needed.
• Patient education on safe sexual practices to prevent transmission.

Infection Control:

• Encourage safe sex practices to reduce transmission risk.
• Screening and treatment of sexual partners.
• Public health reporting in endemic areas to monitor outbreaks.

How to Document Symptoms of Granuloma inguinale (ICD-10 A58) in SOAP Notes

Subjective:

• Patient reports painless ulceration in the genital area.
• History of sexual activity with multiple partners.
• No significant pain or discomfort associated with lesions.
• Denies fever or systemic symptoms.

Objective:

• Physical examination reveals multiple beefy-red ulcers.
• Ulcers are well-defined, with no necrotic tissue.
• No lymphadenopathy noted in the groin.
• Vital signs within normal limits.

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SOAP Note Guidelines for Diagnosing Granuloma inguinale (ICD-10 Code A58)

Assessment:

• Diagnosis: Granuloma inguinale, mild severity.
• ICD-10 Code: A58.
• Contributing factors: Recent sexual activity, lack of barrier protection.
• No signs of systemic infection.

Plan:

• Initiate antibiotic therapy with Azithromycin 1g weekly for 3 weeks.
• Educate patient on safe sexual practices and the importance of partner treatment.
• Schedule follow-up in 3 weeks to assess treatment response.
• Monitor for any signs of secondary infection.

Treatment & Plan Section for ICD-10 Code A58 – Granuloma inguinale

• First-line treatment includes Azithromycin or Doxycycline.
• Non-pharmacologic strategies include patient education on hygiene and safe sex.
• Monitoring for treatment efficacy through follow-up visits.
• Encourage reporting of any new lesions or symptoms.

Using ICD-10 Code A58 for Granuloma inguinale in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings in the Subjective and Objective sections.
• Use ICD-10 Code A58 for all related billing to support the diagnosis.
• Align treatment plans with clinical guidelines to justify billing.
• Include relevant CPT codes that correspond to the services provided.

Related ICD-10 Codes Often Used with Granuloma inguinale

• A54.9 – Unspecified gonococcal infection
• A60.9 – Unspecified anogenital herpesviral infection
• A63.0 – Anogenital warts
• A69.2 – Other spirochetal infections

ICD-10 Code A58 in Medical Billing and Insurance for Granuloma inguinale

ICD-10 Code A58 is critical in billing for Granuloma inguinale, particularly in hospital, emergency room, or infectious disease care settings.

Billing Notes:

• Document all relevant patient history and clinical findings to support the use of A58.
• Ensure that the diagnosis is clearly linked to the treatment provided.
• Use A58 in conjunction with appropriate CPT codes for accurate billing.
• Review payer-specific guidelines for any additional documentation requirements.

Common CPT Pairings: