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ICD-10 Guide
ICD-10 CodesA54.00

A54.00

Gonococcal infection of lower genitourinary tract, unspecified

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

Code Description

ICD-10 A54.00 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 women, it can lead to complications such as pelvic inflammatory disease (PID) if left untreated. The unspecified designation indicates that the specific site of infection within the lower genitourinary tract has not been clearly identified. Diagnosis is typically made through laboratory testing, including nucleic acid amplification tests (NAATs) or culture. Treatment usually involves antibiotics, with dual therapy recommended to combat potential antibiotic resistance. Contact tracing is crucial to prevent further transmission, as gonorrhea can be asymptomatic in many individuals. Public health guidelines emphasize the importance of screening high-risk populations and educating patients about safe sexual practices.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in symptoms and presentation among patients
  • Need for accurate documentation of clinical findings
  • Potential for co-infection with other STIs
  • Variability in treatment protocols based on local resistance patterns

Audit Risk Factors

  • Inadequate documentation of symptoms and clinical findings
  • Failure to document patient education on STI prevention
  • Lack of follow-up documentation for treatment efficacy
  • Inconsistent coding of related STIs

Specialty Focus

Medical Specialties

Infectious Disease

Documentation Requirements

Detailed patient history, symptomatology, and laboratory results.

Common Clinical Scenarios

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

Billing Considerations

Consideration of local antibiotic resistance patterns and patient follow-up.

Urology

Documentation Requirements

Clinical findings related to urinary symptoms, diagnostic tests performed.

Common Clinical Scenarios

Management of urethritis and complications from gonococcal infections.

Billing Considerations

Documentation of any surgical interventions or referrals.

Coding Guidelines

Inclusion Criteria

Use A54.00 When
  • According to the official coding guidelines, A54
  • 00 should be used when the gonococcal infection is confirmed but the specific site is not documented
  • Coders should ensure that the diagnosis is supported by appropriate clinical documentation

Exclusion Criteria

Do NOT use A54.00 When
No specific exclusions found.

Related CPT Codes

87491CPT Code

Nucleic acid amplification test for gonorrhea

Clinical Scenario

Used for confirming diagnosis of gonococcal infection.

Documentation Requirements

Document the reason for testing and results.

Specialty Considerations

Infectious disease specialists should ensure proper test selection based on patient history.

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 STIs.

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 STIs.

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 STIs.

Resources

Clinical References

  • •
    CDC Gonorrhea Treatment Guidelines

Coding & Billing References

  • •
    CDC Gonorrhea Treatment Guidelines

Frequently Asked Questions

What is the significance of the unspecified designation in A54.00?

The unspecified designation indicates that the specific site of the gonococcal infection has not been documented, which can affect treatment and follow-up care.