ICD-10 Code A71.1 | Active stage of trachoma Symptoms, Diagnosis, Billing

Active stage of trachoma is characterized by inflammation of the conjunctiva and cornea caused by the Chlamydia trachomatis infection. This condition is clinically significant as it can lead to severe visual impairment if untreated. The ICD-10 Code A71.1 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and track this infectious disease.

What is ICD-10 Code A71.1 for Active stage of trachoma?

ICD-10 Code A71.1 represents the active stage of trachoma, an infectious disease caused by Chlamydia trachomatis. This code should be used in clinical documentation and billing when a patient presents with symptoms indicative of active trachoma, such as conjunctival inflammation and discharge, to ensure appropriate treatment and tracking of the disease.

ICD-10 Code A71.1 – Clinical Definition and Explanation of Active stage of trachoma

Active stage of trachoma is primarily caused by the bacterium Chlamydia trachomatis, leading to inflammation of the conjunctiva and potential scarring of the cornea. This condition requires prompt medical attention to prevent complications such as blindness. Early diagnosis and treatment are crucial for effective management.

Key Clinical Features:

• Conjunctival inflammation and redness
• Mucopurulent discharge from the eye
• Photophobia and tearing
• Follicular conjunctivitis

ICD-10 Code A71.1 for Active stage of trachoma – SOAP Notes & Clinical Use

ICD-10 Code A71.1 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plan for active trachoma. This code 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 A71.1 for Active stage of trachoma Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A71.1 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of active trachoma. This code is essential for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A71.1 – Active stage of trachoma

The active stage of trachoma requires immediate medical intervention to prevent complications. Treatment typically involves antibiotic therapy and supportive care.

Antibiotic Therapy:

• Azithromycin 1 g orally as a single dose
• Doxycycline 100 mg orally twice daily for 7 days
• Tetracycline eye ointment applied 4 times daily for 6 weeks

Supportive Care:

• Warm compresses to relieve discomfort
• Artificial tears to manage dryness
• Education on hygiene practices to prevent spread

Infection Control:

• Isolation of infected individuals during outbreaks
• Hand hygiene education for patients and caregivers
• Avoiding shared personal items like towels

How to Document Symptoms of Active stage of trachoma (ICD-10 A71.1) in SOAP Notes

Subjective:

• Patient reports redness and irritation in both eyes.
• Complains of increased tearing and discharge.
• States sensitivity to light and discomfort when blinking.

Objective:

• Conjunctival injection observed on examination.
• Mucopurulent discharge noted during assessment.
• Visual acuity testing reveals no significant impairment.

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SOAP Note Guidelines for Diagnosing Active stage of trachoma (ICD-10 Code A71.1)

Assessment:

• Diagnosis: Active stage of trachoma (ICD-10 A71.1).
• Severity: Moderate, based on clinical findings.
• Contributing factors: Recent travel to endemic area.

Plan:

• Initiate treatment with Azithromycin 1 g orally.
• Educate patient on hygiene practices to prevent spread.
• Schedule follow-up in one week to assess treatment response.

Treatment & Plan Section for ICD-10 Code A71.1 – Active stage of trachoma

• First-line antibiotic therapy with Azithromycin.
• Supportive care including warm compresses and artificial tears.
• Patient education on hygiene and infection control measures.
• Follow-up appointment to monitor treatment efficacy.

Using ICD-10 Code A71.1 for Active stage of trachoma in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings.
• Use A71.1 in conjunction with appropriate CPT codes for billing.
• Maintain compliance with EHR standards for documentation.
• Document patient education and follow-up plans clearly.

Related ICD-10 Codes Often Used with Active stage of trachoma

• A71.0 – Inactive stage of trachoma
• H10.1 – Acute conjunctivitis
• H00.0 – Chalazion
• H10.9 – Conjunctivitis, unspecified

ICD-10 Code A71.1 in Medical Billing and Insurance for Active stage of trachoma

ICD-10 Code A71.1 is crucial for billing in hospital, ER, or infectious disease care settings, ensuring accurate reimbursement for services rendered.

Billing Notes:

• Document all relevant clinical findings to support the diagnosis.
• Use A71.1 in the primary diagnosis field for billing.
• Include patient education and follow-up in documentation.

Common CPT Pairings: