ICD-10 Code A74.9 | Chlamydial infection, unspecified Symptoms, Diagnosis, Billing

Chlamydial infection, unspecified, is a sexually transmitted infection caused by the bacterium Chlamydia trachomatis. It is clinically significant due to its potential to cause serious reproductive health issues, including infertility and pelvic inflammatory disease. Accurate coding with ICD-10 Code A74.9 facilitates proper diagnosis, documentation, medical billing, and public health reporting, ensuring effective management and treatment of the infection.

What is ICD-10 Code A74.9 for Chlamydial infection, unspecified?

ICD-10 Code A74.9 represents a diagnosis of chlamydial infection that is unspecified, indicating the presence of the infection without detailing the specific site or manifestation. This code is used when a patient presents with symptoms suggestive of chlamydia but lacks specific localization or when laboratory confirmation is pending. It is essential for accurate clinical documentation and billing.

ICD-10 Code A74.9 – Clinical Definition and Explanation of Chlamydial infection, unspecified

Chlamydial infection, unspecified, is primarily caused by Chlamydia trachomatis, a common sexually transmitted pathogen. The infection can be asymptomatic or lead to significant complications if untreated, necessitating medical evaluation and intervention.

Key Clinical Features:

• Asymptomatic in many cases, particularly in women.
• Possible symptoms include abnormal genital discharge, dysuria, and pelvic pain.
• Increased risk of developing pelvic inflammatory disease (PID) and infertility.
• Higher prevalence in sexually active adolescents and young adults.

ICD-10 Code A74.9 for Chlamydial infection, unspecified – SOAP Notes & Clinical Use

ICD-10 Code A74.9 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 patient management and facilitating appropriate billing.

What Does ICD-10 Code A74.9 for Chlamydial infection, unspecified Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A74.9 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of chlamydial infection. This code supports continuity of care, aids in billing processes, and meets EHR documentation standards.

Treatment Options for ICD-10 Code A74.9 – Chlamydial infection, unspecified

Chlamydial infection requires prompt treatment to prevent complications. Antibiotic therapy is the cornerstone of management.

Antibiotic Therapy:

• Azithromycin 1 g orally in a single dose.
• Doxycycline 100 mg orally twice daily for 7 days.
• Alternative: Levofloxacin 500 mg orally once daily for 7 days.

Supportive Care:

• Patient education on safe sex practices.
• Counseling on the importance of partner notification and treatment.
• Symptomatic relief for dysuria or pelvic pain.

Infection Control:

• Encourage regular screening in sexually active individuals.
• Implement safe sex practices to prevent transmission.
• Notify and treat sexual partners to reduce reinfection risk.

How to Document Symptoms of Chlamydial infection, unspecified (ICD-10 A74.9) in SOAP Notes

Subjective:

• Patient reports abnormal vaginal discharge.
• Complaints of dysuria and pelvic discomfort.
• History of unprotected sexual intercourse.
• No previous diagnosis of sexually transmitted infections.

Objective:

• Physical examination reveals cervical tenderness.
• Presence of mucopurulent discharge on pelvic exam.
• Negative urine pregnancy test.
• Vital signs within normal limits.

Secure, compliant, and built for trust

HIPAA-compliant and designed with privacy in mind, your patient’s data is protected. Focus on care while we safeguard your information.

Learn more

SOAP Note Guidelines for Diagnosing Chlamydial infection, unspecified (ICD-10 Code A74.9)

Assessment:

• Diagnosis: Chlamydial infection, unspecified (ICD-10 A74.9).
• Severity: Mild, based on clinical presentation.
• Contributing factors: Recent unprotected sexual activity.
• Consider differential diagnoses such as gonorrhea or bacterial vaginosis.

Plan:

• Initiate treatment with Azithromycin 1 g orally.
• Educate patient on safe sexual practices and the importance of partner treatment.
• Schedule follow-up in 1 week to reassess symptoms.
• Consider retesting for STIs in 3 months.

Treatment & Plan Section for ICD-10 Code A74.9 – Chlamydial infection, unspecified

• First-line treatment with Azithromycin or Doxycycline.
• Counseling on safe sex practices and partner notification.
• Monitoring for symptom resolution and potential complications.
• Follow-up testing for reinfection after treatment.

Using ICD-10 Code A74.9 for Chlamydial infection, unspecified in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings in SOAP notes.
• Use A74.9 when the specific site of infection is not identified.
• Align treatment plans with clinical guidelines to support billing.
• Include relevant CPT codes for laboratory tests and consultations.

Related ICD-10 Codes Often Used with Chlamydial infection, unspecified

• A74.0 – Chlamydial infection of the lower genitourinary tract
• A74.1 – Chlamydial infection of the upper genitourinary tract
• A74.8 – Other chlamydial infections
• A54.9 – Gonococcal infection, unspecified

ICD-10 Code A74.9 in Medical Billing and Insurance for Chlamydial infection, unspecified

ICD-10 Code A74.9 is crucial for billing in hospital, ER, or infectious disease settings, ensuring accurate reimbursement for services rendered.

Billing Notes:

• Document all relevant patient history and clinical findings to support the diagnosis.
• Use A74.9 in cases where the infection site is not specified.
• Ensure compliance with payer requirements for documentation.
• Include follow-up care and education in the treatment plan.

Common CPT Pairings: