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v1.0.0
ICD-10 Guide
ICD-10 CodesA52.9

A52.9

Late syphilis, unspecified

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

Code Description

ICD-10 A52.9 is a billable code used to indicate a diagnosis of late syphilis, unspecified.

Key Diagnostic Point:

Late syphilis, unspecified, refers to the advanced stage of syphilis infection that occurs after the primary and secondary stages have resolved. This stage can manifest years after the initial infection and is characterized by the potential for severe systemic complications. Patients may present with gummatous lesions, cardiovascular syphilis, or neurosyphilis, which can affect various organ systems. The absence of specific symptoms or documentation of the exact manifestations can lead to the classification as 'unspecified.' Late syphilis is primarily transmitted through sexual contact, and its diagnosis often requires serological testing, including non-treponemal and treponemal tests. Treatment typically involves high-dose penicillin, and follow-up is crucial to monitor for treatment efficacy and potential complications. Contact tracing is essential to prevent further transmission, as many individuals may be asymptomatic yet infectious.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation and symptoms
  • Need for comprehensive patient history and serological testing
  • Potential for co-infections with other STIs
  • Documentation requirements for late-stage manifestations

Audit Risk Factors

  • Inadequate documentation of symptoms and history
  • Failure to document treatment response
  • Lack of follow-up notes
  • Misclassification of stage due to incomplete information

Specialty Focus

Medical Specialties

Infectious Disease

Documentation Requirements

Detailed patient history, serological test results, and treatment plans.

Common Clinical Scenarios

Patients presenting with late-stage symptoms or complications from syphilis.

Billing Considerations

Ensure all manifestations are documented to support the diagnosis.

Primary Care

Documentation Requirements

Comprehensive sexual history, risk factors, and follow-up care documentation.

Common Clinical Scenarios

Routine screenings in high-risk populations and management of syphilis treatment.

Billing Considerations

Coordination with infectious disease specialists for complex cases.

Coding Guidelines

Inclusion Criteria

Use A52.9 When
  • Follow ICD
  • CM guidelines for coding syphilis, ensuring accurate documentation of the stage and manifestations
  • Include relevant patient history and serological test results to support the diagnosis

Exclusion Criteria

Do NOT use A52.9 When
No specific exclusions found.

Related CPT Codes

86592CPT Code

Syphilis serology test

Clinical Scenario

Used for initial diagnosis and follow-up of syphilis treatment.

Documentation Requirements

Document the reason for testing and results.

Specialty Considerations

Infectious disease specialists may require additional serological tests.

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 treatment tracking. A52.9 provides a clear designation for late syphilis, facilitating better patient management and epidemiological tracking.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of syphilis stages, improving data accuracy and treatment tracking. A52.9 provides a clear designation for late syphilis, facilitating better patient management and epidemiological tracking.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of syphilis stages, improving data accuracy and treatment tracking. A52.9 provides a clear designation for late syphilis, facilitating better patient management and epidemiological tracking.

Resources

Clinical References

  • •
    CDC Syphilis Fact Sheet

Coding & Billing References

  • •
    CDC Syphilis Fact Sheet

Frequently Asked Questions

What are the common symptoms of late syphilis?

Common symptoms include gummatous lesions, neurological symptoms, and cardiovascular issues. Patients may also be asymptomatic.

How is late syphilis treated?

Treatment typically involves high-dose penicillin G, with follow-up serological testing to monitor treatment response.