ICD-10 Code A74.81 | Chlamydial peritonitis Symptoms, Diagnosis, Billing

Chlamydial peritonitis is an inflammatory condition of the peritoneum caused by Chlamydia trachomatis infection, often resulting from pelvic inflammatory disease (PID). It is clinically significant due to its potential complications, including abscess formation and sepsis. Accurate coding with ICD-10 Code A74.81 facilitates precise diagnosis, documentation, medical billing, and public health reporting, ensuring appropriate management and resource allocation.

What is ICD-10 Code A74.81 for Chlamydial peritonitis?

ICD-10 Code A74.81 specifically denotes Chlamydial peritonitis, an infection of the peritoneal cavity primarily caused by Chlamydia trachomatis. This code should be utilized in clinical documentation and billing when diagnosing patients with this condition, particularly in cases linked to PID or other complications arising from chlamydial infections.

ICD-10 Code A74.81 – Clinical Definition and Explanation of Chlamydial peritonitis

Chlamydial peritonitis arises from the spread of Chlamydia trachomatis, often following untreated or inadequately treated pelvic inflammatory disease. The condition can progress rapidly, necessitating prompt medical intervention to prevent severe complications. Symptoms may include abdominal pain, fever, and gastrointestinal disturbances.

Key Clinical Features:

• Abdominal pain and tenderness, particularly in the lower quadrants.
• Fever and chills indicating systemic infection.
• Nausea and vomiting, potentially leading to dehydration.
• Signs of peritoneal irritation on physical examination.

ICD-10 Code A74.81 for Chlamydial peritonitis – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code A74.81 is essential for documenting the patient's symptoms, assessment findings, and treatment plans. It is relevant in both acute and chronic care settings, ensuring comprehensive patient management and facilitating accurate billing.

What Does ICD-10 Code A74.81 for Chlamydial peritonitis Mean in SOAP Notes?

ICD-10 Code A74.81 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Chlamydial peritonitis. This code is crucial for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A74.81 – Chlamydial peritonitis

Chlamydial peritonitis requires urgent medical attention, often necessitating hospitalization for effective management. Appropriate antibiotic therapy is critical to address the infection.

Antibiotic Therapy:

• Azithromycin 1 g orally in a single dose or Doxycycline 100 mg orally twice daily for 7 days.
• Alternative: Ofloxacin 400 mg orally twice daily for 7 days.
• Consideration of intravenous antibiotics in severe cases.

Supportive Care:

• Intravenous fluids to maintain hydration.
• Pain management with analgesics.
• Monitoring for signs of complications such as abscess formation.

Infection Control:

• Strict adherence to hand hygiene practices.
• Isolation precautions if indicated during outbreaks.
• Education on safe sexual practices to prevent transmission.

How to Document Symptoms of Chlamydial peritonitis (ICD-10 A74.81) in SOAP Notes

Subjective:

• Patient reports severe lower abdominal pain, worsening over the past 24 hours.
• History of recent pelvic inflammatory disease treated with antibiotics.
• Complaints of nausea and intermittent vomiting.
• Fever reported at home, with chills and malaise.

Objective:

• Vital signs: Temperature 101°F, heart rate 110 bpm, blood pressure 100/60 mmHg.
• Abdominal examination reveals tenderness in the lower quadrants with rebound tenderness.
• Bowel sounds decreased on auscultation.
• Laboratory tests show elevated white blood cell count.

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SOAP Note Guidelines for Diagnosing Chlamydial peritonitis (ICD-10 Code A74.81)

Assessment:

• Diagnosis: Chlamydial peritonitis, moderate severity.
• ICD-10 Code: A74.81.
• Contributing factors: Recent history of untreated pelvic inflammatory disease.
• Consideration of potential complications such as abscess formation.

Plan:

• Initiate antibiotic therapy with Azithromycin or Doxycycline.
• Administer IV fluids for hydration and electrolyte balance.
• Monitor vital signs and abdominal symptoms closely.
• Schedule follow-up imaging if symptoms do not improve within 48 hours.

Treatment & Plan Section for ICD-10 Code A74.81 – Chlamydial peritonitis

• First-line pharmacologic treatment includes Azithromycin or Doxycycline.
• Non-pharmacologic strategies involve hydration and nutritional support.
• Monitoring includes regular assessment of vital signs and abdominal symptoms.
• Follow-up imaging may be necessary to evaluate for complications.

Using ICD-10 Code A74.81 for Chlamydial peritonitis in Billing & SOAP Note Compliance

• Select accurate subcodes based on clinical severity or complications.
• Document symptoms clearly under Subjective (S) and Objective (O) in SOAP notes.
• Ensure treatment plans align with clinical guidelines to support justified billing.
• Only list CPT codes that are commonly billed with ICD-10 Code A74.81 based on standard medical coding practices.

Related ICD-10 Codes Often Used with Chlamydial peritonitis

• A74.0 – Chlamydial infection of the lower genitourinary tract
• A74.9 – Chlamydial infection, unspecified
• N70.9 – Pelvic inflammatory disease, unspecified
• N73.9 – Other female pelvic inflammatory disease, unspecified

ICD-10 Code A74.81 in Medical Billing and Insurance for Chlamydial peritonitis

ICD-10 Code A74.81 is crucial for billing in hospital, ER, or infectious disease care settings, ensuring accurate reimbursement for services rendered.

Billing Notes:

• Document all relevant patient history and clinical findings to support the diagnosis.
• Use the code in conjunction with appropriate CPT codes for comprehensive billing.
• Ensure that the documentation reflects the severity and complexity of the condition.
• Review payer-specific guidelines for coding and billing compliance.

Common CPT Pairings: