ICD-10 Code A65 | Nonvenereal syphilis Symptoms, Diagnosis, Billing

Nonvenereal syphilis is a chronic infectious disease caused by the bacterium Treponema pallidum, primarily transmitted through nonsexual means, such as direct contact with infected skin or mucous membranes. It is clinically significant due to its potential to cause serious health complications if left untreated. The ICD-10 Code A65 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and track cases of this condition.

What is ICD-10 Code A65 for Nonvenereal syphilis?

ICD-10 Code A65 represents Nonvenereal syphilis, a form of syphilis that is not transmitted through sexual contact. This condition is associated with various clinical manifestations and can lead to significant morbidity if not addressed. The code should be used in clinical documentation and billing when diagnosing patients with this specific form of syphilis, ensuring proper categorization and treatment.

ICD-10 Code A65 – Clinical Definition and Explanation of Nonvenereal syphilis

Nonvenereal syphilis is caused by the bacterium Treponema pallidum, which can be transmitted through nonsexual routes, including direct contact with lesions. The disease can progress through several stages, leading to systemic complications if untreated. Medical attention is crucial for effective management and prevention of long-term health issues.

Key Clinical Features:

• Presence of skin lesions or mucous membrane ulcers.
• Potential systemic involvement, including neurological or cardiovascular complications.
• History of exposure to infected individuals or contaminated environments.
• Symptoms may mimic other conditions, necessitating differential diagnosis.

ICD-10 Code A65 for Nonvenereal syphilis – SOAP Notes & Clinical Use

ICD-10 Code A65 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans related to Nonvenereal syphilis. 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 A65 for Nonvenereal syphilis Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A65 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Nonvenereal syphilis. This code plays a vital role in ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A65 – Nonvenereal syphilis

Nonvenereal syphilis requires prompt medical intervention to prevent complications. Treatment typically involves antibiotic therapy, and supportive care may be necessary to manage symptoms.

Antibiotic Therapy:

• Benzathine penicillin G: 2.4 million units IM once.
• Doxycycline: 100 mg orally twice daily for 14 days (alternative).
• Tetracycline: 500 mg orally four times daily for 14 days (alternative).

Supportive Care:

• Pain management with analgesics as needed.
• Monitoring for potential complications.
• Patient education on disease transmission and prevention.

Infection Control:

• Implement standard precautions to prevent transmission.
• Educate patients on avoiding contact with lesions.
• Report cases to public health authorities as required.

How to Document Symptoms of Nonvenereal syphilis (ICD-10 A65) in SOAP Notes

Subjective:

• Patient reports skin lesions with associated itching.
• History of exposure to individuals with similar symptoms.
• Complaints of fatigue and malaise.
• No recent sexual activity reported.

Objective:

• Physical examination reveals ulcerated lesions on the skin.
• Lymphadenopathy noted in regional lymph nodes.
• Vital signs stable; no fever present.
• Laboratory tests confirm Treponema pallidum infection.

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SOAP Note Guidelines for Diagnosing Nonvenereal syphilis (ICD-10 Code A65)

Assessment:

• Diagnosis: Nonvenereal syphilis, confirmed by serological testing.
• Severity: Moderate, with systemic involvement.
• Contributing factors: Recent exposure to infected individuals.
• ICD-10 Code: A65.

Plan:

• Initiate treatment with Benzathine penicillin G.
• Educate patient on disease transmission and prevention strategies.
• Schedule follow-up appointment in 2 weeks to monitor treatment response.
• Consider referral to infectious disease specialist if complications arise.

Treatment & Plan Section for ICD-10 Code A65 – Nonvenereal syphilis

• First-line treatment with Benzathine penicillin G.
• Alternative antibiotics include doxycycline or tetracycline.
• Patient education on avoiding contact with lesions and transmission prevention.
• Regular follow-up to monitor treatment efficacy and manage any complications.

Using ICD-10 Code A65 for Nonvenereal syphilis in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings in SOAP notes.
• Use ICD-10 Code A65 for billing related to Nonvenereal syphilis treatment.
• Align treatment plans with clinical guidelines to support justified billing.
• Document any relevant comorbidities or complications to enhance coding accuracy.

Related ICD-10 Codes Often Used with Nonvenereal syphilis

ICD-10 Code A65 in Medical Billing and Insurance for Nonvenereal syphilis

ICD-10 Code A65 is essential for accurate billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant patient history and clinical findings to support the ICD-10 claim.
• Use A65 in conjunction with other codes for comprehensive billing.
• Ensure that treatment plans are clearly outlined in the medical record.

Common CPT Pairings: