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ICD-10 Guide
ICD-10 CodesA54.0

A54.0

Gonococcal infection of lower genitourinary tract, unspecified

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

Code Description

ICD-10 A54.0 is a billable code used to indicate a diagnosis of gonococcal infection of lower genitourinary tract, unspecified.

Key Diagnostic Point:

Gonococcal infection of the lower genitourinary tract is a sexually transmitted infection caused by the bacterium Neisseria gonorrhoeae. This infection primarily affects the urethra in men and the cervix in women, but it can also involve the rectum and throat. Symptoms may include dysuria, increased urinary frequency, purulent discharge, and pelvic pain. In some cases, the infection can be asymptomatic, particularly in women, which can lead to complications such as pelvic inflammatory disease (PID) if left untreated. Diagnosis is typically made through nucleic acid amplification tests (NAATs) or culture methods. Treatment usually involves a dual therapy regimen of antibiotics, commonly ceftriaxone and azithromycin, to effectively eradicate the infection and prevent the development of antibiotic resistance. Contact tracing is crucial for managing gonococcal infections, as it helps identify and treat sexual partners to prevent reinfection and further transmission.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation (asymptomatic cases)
  • Need for accurate documentation of sexual history
  • Potential for co-infection with other STIs
  • Variability in treatment regimens based on local guidelines

Audit Risk Factors

  • Inadequate documentation of symptoms and clinical findings
  • Failure to document treatment regimens
  • Lack of follow-up care documentation
  • Insufficient details on patient education regarding STI prevention

Specialty Focus

Medical Specialties

Infectious Disease

Documentation Requirements

Detailed patient history, including sexual history and previous STIs.

Common Clinical Scenarios

Diagnosis and management of gonococcal infections, treatment of co-infections.

Billing Considerations

Documentation of antibiotic resistance patterns and follow-up testing.

Urology

Documentation Requirements

Clinical findings related to urinary symptoms and any complications.

Common Clinical Scenarios

Management of urethritis and complications such as epididymitis.

Billing Considerations

Need for clear documentation of diagnostic tests and treatment plans.

Coding Guidelines

Inclusion Criteria

Use A54.0 When
  • According to ICD
  • 10 guidelines, A54
  • 0 should be used when the gonococcal infection is confirmed but the specific site of infection is not documented
  • It is important to ensure that the diagnosis is supported by laboratory findings

Exclusion Criteria

Do NOT use A54.0 When
No specific exclusions found.

Related CPT Codes

87491CPT Code

Nucleic acid amplification test for gonorrhea

Clinical Scenario

Used for confirming gonococcal infection in symptomatic patients.

Documentation Requirements

Document the reason for testing and the patient's symptoms.

Specialty Considerations

Infectious disease specialists may require additional details on treatment response.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of gonococcal infections, improving data accuracy and facilitating better tracking of STI trends.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of gonococcal infections, improving data accuracy and facilitating better tracking of STI trends.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of gonococcal infections, improving data accuracy and facilitating better tracking of STI trends.

Resources

Clinical References

  • •
    CDC Gonorrhea Treatment Guidelines

Coding & Billing References

  • •
    CDC Gonorrhea Treatment Guidelines

Frequently Asked Questions

What are the common symptoms of gonococcal infection?

Common symptoms include dysuria, purulent discharge, and pelvic pain. However, many individuals may be asymptomatic.

How is gonococcal infection treated?

Treatment typically involves a dual therapy regimen of ceftriaxone and azithromycin to effectively treat the infection.

Why is contact tracing important for gonococcal infections?

Contact tracing helps identify and treat sexual partners, reducing the risk of reinfection and further transmission of the disease.