Gonococcal infection
ICD-10 A54 is a billable code used to indicate a diagnosis of gonococcal infection.
Gonococcal infection, caused by the bacterium Neisseria gonorrhoeae, is a common sexually transmitted infection (STI) that primarily affects the mucous membranes of the urogenital tract, but can also infect the rectum, throat, and conjunctiva. The infection is transmitted through sexual contact with an infected person, and it can occur in both men and women. Symptoms may include dysuria, increased vaginal or penile discharge, and pelvic pain, although many individuals remain asymptomatic. Complications can arise if left untreated, including pelvic inflammatory disease (PID) in women, which can lead to infertility, and disseminated gonococcal infection (DGI), which can cause arthritis and skin lesions. Diagnosis is typically made through nucleic acid amplification tests (NAATs) or culture methods. Treatment guidelines recommend dual therapy with ceftriaxone and azithromycin to combat antibiotic resistance. Contact tracing is crucial for preventing further transmission, as partners of infected individuals should be notified and tested. Regular screening is recommended for high-risk populations, including sexually active adolescents and young adults.
Detailed patient history, including sexual history and previous STIs, treatment plans, and follow-up care.
Diagnosis and management of gonococcal infections, treatment of complications like PID, and management of co-infections.
Ensure documentation reflects the complexity of the case, including any complications or co-infections.
Documentation of pelvic exams, symptoms, treatment plans, and follow-up visits.
Management of pelvic inflammatory disease due to gonococcal infection and routine STI screenings.
Document any findings from pelvic exams and the patient's sexual history to support coding.
Used when testing for gonococcal infection in symptomatic or asymptomatic patients.
Document the reason for testing and the patient's symptoms.
Infectious disease specialists should ensure comprehensive STI screening.
The primary treatment for gonococcal infection is dual therapy with ceftriaxone and azithromycin, as recommended by the CDC to combat antibiotic resistance.
