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v1.0.0
ICD-10 Guide
ICD-10 CodesA53.9

A53.9

Syphilis, unspecified

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

Code Description

ICD-10 A53.9 is a billable code used to indicate a diagnosis of syphilis, unspecified.

Key Diagnostic Point:

Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum. It is characterized by distinct stages: primary, secondary, latent, and tertiary, each with varying symptoms and potential complications. The primary stage typically presents with a painless ulcer known as a chancre, while secondary syphilis may manifest with systemic symptoms such as rashes, mucous membrane lesions, and flu-like symptoms. Latent syphilis is asymptomatic, and tertiary syphilis can lead to severe complications affecting the cardiovascular system, nervous system, and other organs. The unspecified designation (A53.9) is used when the specific stage of syphilis is not documented or when the diagnosis is made without further specification. Accurate diagnosis and treatment are crucial to prevent long-term health issues and transmission to others. Treatment typically involves antibiotics, with penicillin being the most effective. Contact tracing is essential for managing syphilis outbreaks, as it helps identify and treat partners to reduce transmission rates.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation across different stages of syphilis.
  • Need for precise documentation of symptoms and stage for accurate coding.
  • Potential for misdiagnosis with other STIs or conditions.
  • Importance of contact tracing and partner notification in treatment plans.

Audit Risk Factors

  • Inadequate documentation of the stage of syphilis.
  • Failure to document patient history related to sexual partners.
  • Lack of follow-up documentation for treatment efficacy.
  • Inconsistent coding practices among different providers.

Specialty Focus

Medical Specialties

Infectious Disease

Documentation Requirements

Detailed patient history, including sexual history and previous STI diagnoses.

Common Clinical Scenarios

Diagnosis of syphilis in patients presenting with genital ulcers or rashes.

Billing Considerations

Consideration of co-infections with other STIs and the need for comprehensive treatment plans.

Primary Care

Documentation Requirements

Thorough documentation of symptoms, risk factors, and treatment plans.

Common Clinical Scenarios

Routine screening for STIs in high-risk populations.

Billing Considerations

Importance of patient education on STI prevention and the need for follow-up.

Coding Guidelines

Inclusion Criteria

Use A53.9 When
  • According to ICD
  • 10 coding guidelines, A53
  • 9 should be used when the specific stage of syphilis is not documented
  • Coders should ensure that the diagnosis is supported by clinical documentation and that any related symptoms or conditions are also coded appropriately

Exclusion Criteria

Do NOT use A53.9 When
No specific exclusions found.

Related CPT Codes

86592CPT Code

Syphilis serology test

Clinical Scenario

Used for screening or confirming syphilis diagnosis.

Documentation Requirements

Document the reason for testing and results.

Specialty Considerations

Infectious disease specialists may require additional tests for co-infections.

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. A53.9 serves as a catch-all for unspecified cases, but coders must strive for specificity when possible.

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. A53.9 serves as a catch-all for unspecified cases, but coders must strive for specificity when possible.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of syphilis stages, improving data accuracy and treatment tracking. A53.9 serves as a catch-all for unspecified cases, but coders must strive for specificity when possible.

Resources

Clinical References

  • •
    CDC Syphilis Fact Sheet

Coding & Billing References

  • •
    CDC Syphilis Fact Sheet

Frequently Asked Questions

When should I use A53.9 instead of a more specific code?

A53.9 should be used when the specific stage of syphilis is not documented or when the diagnosis is made without further specification. Always strive for the most specific code available.