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ICD-10 Guide
ICD-10 CodesA51.1

A51.1

Early congenital syphilis

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

Code Description

ICD-10 A51.1 is a billable code used to indicate a diagnosis of early congenital syphilis.

Key Diagnostic Point:

Early congenital syphilis refers to the manifestation of syphilis in infants who acquire the infection in utero from an infected mother. This condition typically presents within the first two years of life and can lead to severe complications if not treated promptly. Symptoms may include skin rashes, fever, irritability, and skeletal abnormalities. The infection is caused by the bacterium Treponema pallidum, which can cross the placental barrier during pregnancy. Early diagnosis and treatment are crucial to prevent long-term health issues, including neurological damage and developmental delays. Treatment usually involves the administration of penicillin, which is effective in eradicating the infection. Contact tracing is essential to identify and treat the mother and any sexual partners to prevent further transmission. Surveillance and screening for syphilis in pregnant women are vital components of prenatal care to reduce the incidence of congenital syphilis.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between early and late congenital syphilis
  • Need for accurate maternal history and documentation
  • Potential for co-infection with other STIs
  • Variability in clinical presentation among infants

Audit Risk Factors

  • Inadequate documentation of maternal syphilis status
  • Failure to document treatment provided to the infant
  • Lack of follow-up care records
  • Inconsistent reporting of symptoms

Specialty Focus

Medical Specialties

Pediatrics

Documentation Requirements

Detailed clinical notes on infant symptoms, maternal history, and treatment plans.

Common Clinical Scenarios

Infants presenting with rashes, fever, or other signs of congenital infection.

Billing Considerations

Ensure thorough documentation of maternal syphilis screening and treatment history.

Obstetrics

Documentation Requirements

Complete prenatal records, including syphilis screening results and treatment provided.

Common Clinical Scenarios

Pregnant women diagnosed with syphilis and their management.

Billing Considerations

Documenting partner treatment and follow-up care is crucial.

Coding Guidelines

Inclusion Criteria

Use A51.1 When
  • According to ICD
  • 10 coding guidelines, A51
  • 1 should be used when there is clear documentation of early congenital syphilis
  • It is important to include the mother's syphilis status and treatment history in the medical record

Exclusion Criteria

Do NOT use A51.1 When
  • Exclusion criteria include cases where syphilis is not confirmed or where the infant's symptoms are attributed to other conditions

Related CPT Codes

86592CPT Code

Syphilis serology test

Clinical Scenario

Used to confirm syphilis infection in pregnant women or newborns.

Documentation Requirements

Document the reason for testing and results.

Specialty Considerations

Pediatricians should ensure maternal history is included.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of congenital syphilis, improving data accuracy and enabling better tracking of public health trends related to this infection.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of congenital syphilis, improving data accuracy and enabling better tracking of public health trends related to this infection.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of congenital syphilis, improving data accuracy and enabling better tracking of public health trends related to this infection.

Resources

Clinical References

  • •
    CDC Syphilis Fact Sheet

Coding & Billing References

  • •
    CDC Syphilis Fact Sheet

Frequently Asked Questions

What is the significance of contact tracing in early congenital syphilis?

Contact tracing is crucial in early congenital syphilis to identify and treat the mother and any sexual partners, thereby preventing further transmission of the infection and protecting future pregnancies.