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v1.0.0
ICD-10 Guide
ICD-10 CodesA51

A51

Early syphilis, unspecified

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 A51 is a billable code used to indicate a diagnosis of early syphilis, unspecified.

Key Diagnostic Point:

Early syphilis, unspecified, refers to the initial stage of syphilis infection, which is a sexually transmitted infection caused by the bacterium Treponema pallidum. This stage is characterized by the presence of a painless ulcer, known as a chancre, at the site of infection, typically occurring 10 to 90 days after exposure. The chancre may heal spontaneously within a few weeks, but without treatment, the infection can progress to secondary syphilis, which involves systemic manifestations such as rashes, mucous membrane lesions, and lymphadenopathy. Early syphilis is crucial to identify and treat promptly to prevent complications and transmission to sexual partners. Diagnosis is typically made through serological testing, including non-treponemal tests (e.g., RPR, VDRL) and treponemal tests (e.g., FTA-ABS). Treatment usually involves the administration of benzathine penicillin G, which is effective in eradicating the infection. Contact tracing is essential to identify and treat sexual partners to prevent further spread of the infection. Public health guidelines recommend routine screening for high-risk populations, including sexually active individuals and those with multiple partners.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation and symptoms.
  • Need for accurate serological testing interpretation.
  • Differentiation from other sexually transmitted infections.
  • Importance of thorough documentation for treatment and follow-up.

Audit Risk Factors

  • Inadequate documentation of clinical findings.
  • Failure to document patient history and risk factors.
  • Lack of follow-up care documentation.
  • Inconsistent coding of related STIs.

Specialty Focus

Medical Specialties

Infectious Disease

Documentation Requirements

Detailed patient history, clinical findings, and treatment plans.

Common Clinical Scenarios

Diagnosis and management of early syphilis in high-risk populations.

Billing Considerations

Ensure comprehensive documentation of serological test results and follow-up care.

Primary Care

Documentation Requirements

Routine screening results, patient education on STIs, and treatment adherence.

Common Clinical Scenarios

Screening and treating patients presenting with genital ulcers or other STI symptoms.

Billing Considerations

Documenting patient education and partner notification efforts.

Coding Guidelines

Inclusion Criteria

Use A51 When
  • According to the official coding guidelines, A51 should be used when the clinical documentation supports a diagnosis of early syphilis without further specification
  • It is important to ensure that the diagnosis is confirmed through appropriate serological testing

Exclusion Criteria

Do NOT use A51 When
No specific exclusions found.

Related Codes

Child Codes

17 codes
A51.0
Primary genital syphilis
A51.1
Early congenital syphilis
A51.2
Early congenital syphilis, symptomatic
A51.3
ICD-10 Title: Early congenital syphilis, symptomatic
A51.31
Condyloma latum
A51.32
Syphilitic alopecia
A51.39
Other secondary syphilis of skin
A51.4
Late congenital syphilitic osteochondropathy
A51.41
Secondary syphilitic meningitis
A51.42
Secondary syphilitic female pelvic disease
A51.43
Secondary syphilitic oculopathy
A51.44
Secondary syphilitic nephritis
A51.45
Secondary syphilitic hepatitis
A51.46
Secondary syphilitic osteopathy
A51.49
Other secondary syphilitic conditions
A51.5
Late congenital syphilis, symptomatic
A51.9
Late syphilis, unspecified

Related CPT Codes

86592CPT Code

Syphilis serology test

Clinical Scenario

Used to confirm diagnosis of early syphilis.

Documentation Requirements

Document the reason for testing and results.

Specialty Considerations

Infectious disease specialists may require additional follow-up testing.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of syphilis stages, improving data accuracy and facilitating better tracking of disease prevalence and treatment outcomes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of syphilis stages, improving data accuracy and facilitating better tracking of disease prevalence and treatment outcomes.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of syphilis stages, improving data accuracy and facilitating better tracking of disease prevalence and treatment outcomes.

Resources

Clinical References

  • •
    CDC Syphilis Fact Sheet

Coding & Billing References

  • •
    CDC Syphilis Fact Sheet

Frequently Asked Questions

What are the common symptoms of early syphilis?

Common symptoms include a painless sore (chancre) at the site of infection, swollen lymph nodes, and flu-like symptoms. However, many individuals may be asymptomatic.