ICD-10 Code A60.1 | Herpesviral infection of perianal skin and rectum Symptoms, Diagnosis, Billing

Herpesviral infection of perianal skin and rectum is caused by the herpes simplex virus (HSV), leading to painful lesions and inflammation in the affected area. This condition is clinically significant due to its potential for recurrent episodes and complications, including secondary infections. Accurate coding with ICD-10 Code A60.1 facilitates proper diagnosis, documentation, medical billing, and public health reporting, ensuring appropriate management and treatment.

What is ICD-10 Code A60.1 for Herpesviral infection of perianal skin and rectum?

ICD-10 Code A60.1 specifically denotes herpesviral infection of the perianal skin and rectum, primarily caused by the herpes simplex virus. This code should be utilized in clinical documentation when patients present with symptoms such as pain, itching, or lesions in the perianal area, ensuring accurate billing and tracking of this infectious condition.

ICD-10 Code A60.1 – Clinical Definition and Explanation of Herpesviral infection of perianal skin and rectum

Herpesviral infection of the perianal skin and rectum is primarily caused by the herpes simplex virus type 2 (HSV-2), although HSV-1 can also be implicated. The condition manifests through painful vesicular lesions and can lead to significant discomfort and complications if untreated. Medical attention is crucial to manage symptoms and prevent transmission.

Key Clinical Features:

• Painful vesicular lesions in the perianal region.
• Itching and discomfort during bowel movements.
• Possible systemic symptoms such as fever and malaise.
• History of previous herpes simplex infections.

ICD-10 Code A60.1 for Herpesviral infection of perianal skin and rectum – SOAP Notes & Clinical Use

ICD-10 Code A60.1 is essential in SOAP notes for documenting the patient's symptoms, assessment findings, and treatment plans. It is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the herpesviral infection and guiding appropriate management strategies.

What Does ICD-10 Code A60.1 for Herpesviral infection of perianal skin and rectum Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A60.1 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of herpesviral infection. This code supports continuity of care, facilitates accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code A60.1 – Herpesviral infection of perianal skin and rectum

Prompt treatment of herpesviral infection of the perianal skin and rectum is critical to alleviate symptoms and prevent complications. Hospitalization may be necessary in severe cases.

Antibiotic Therapy:

• Acyclovir: 400 mg orally three times daily for 7-10 days.
• Valacyclovir: 1 g orally twice daily for 7-10 days.
• Famciclovir: 250 mg orally three times daily for 7-10 days.

Supportive Care:

• Topical analgesics to relieve pain.
• Sitz baths to soothe irritation.
• Hydration and rest to support recovery.

Infection Control:

• Educate patients on avoiding sexual contact during outbreaks.
• Encourage hand hygiene to prevent spread.
• Advise on the use of barrier methods to reduce transmission risk.

How to Document Symptoms of Herpesviral infection of perianal skin and rectum (ICD-10 A60.1) in SOAP Notes

Subjective:

• Patient reports painful lesions in the perianal area.
• Complaints of itching and discomfort during bowel movements.
• History of recurrent herpes simplex infections.
• Denies any recent sexual activity.

Objective:

• Physical examination reveals vesicular lesions around the anus.
• Tenderness noted on palpation of the perianal region.
• No signs of systemic infection (e.g., fever, lymphadenopathy).
• Skin examination shows erythema and swelling.

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SOAP Note Guidelines for Diagnosing Herpesviral infection of perianal skin and rectum (ICD-10 Code A60.1)

Assessment:

• Diagnosis: Herpesviral infection of perianal skin and rectum, moderate severity.
• ICD-10 Code: A60.1.
• Contributing factors: History of HSV-2 infection.
• Triggers: Recent stress and immunosuppression.

Plan:

• Initiate antiviral therapy with Acyclovir 400 mg TID for 7 days.
• Educate patient on symptom management and infection control.
• Schedule follow-up in one week to assess treatment response.
• Consider referral to infectious disease specialist if recurrent.

Treatment & Plan Section for ICD-10 Code A60.1 – Herpesviral infection of perianal skin and rectum

• First-line pharmacologic treatment includes Acyclovir or Valacyclovir.
• Non-pharmacologic strategies include sitz baths and topical analgesics.
• Monitor for symptom resolution and potential complications.
• Follow-up appointments to reassess and adjust treatment as necessary.

Using ICD-10 Code A60.1 for Herpesviral infection of perianal skin and rectum in Billing & SOAP Note Compliance

• Select appropriate ICD-10 code based on clinical findings.
• Document symptoms clearly under Subjective (S) and Objective (O) sections.
• Ensure treatment plans align with clinical guidelines for justified billing.
• Include relevant CPT codes for services rendered during the visit.

Related ICD-10 Codes Often Used with Herpesviral infection of perianal skin and rectum

• A60.0 – Herpesviral infection of skin and mucous membranes, unspecified
• A60.2 – Herpesviral infection of other sites
• B00.1 – Herpesviral infection of lip
• B00.2 – Herpesviral infection of eyelid and periocular area

ICD-10 Code A60.1 in Medical Billing and Insurance for Herpesviral infection of perianal skin and rectum

ICD-10 Code A60.1 is crucial for accurate billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Ensure documentation supports the diagnosis and treatment provided.
• Use the code in conjunction with relevant clinical findings for claims.
• Include patient history and symptomatology in the medical record.

Common CPT Pairings: