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ICD-10 Guide
ICD-10 CodesA54.03

A54.03

Gonococcal cervicitis, unspecified

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

Code Description

ICD-10 A54.03 is a billable code used to indicate a diagnosis of gonococcal cervicitis, unspecified.

Key Diagnostic Point:

Gonococcal cervicitis is an inflammation of the cervix caused by the Neisseria gonorrhoeae bacterium, a common sexually transmitted infection (STI). This condition often presents with symptoms such as abnormal vaginal discharge, pelvic pain, and bleeding between periods, although many individuals may be asymptomatic. The diagnosis is typically confirmed through laboratory testing, including nucleic acid amplification tests (NAATs) or culture methods. Gonococcal cervicitis can lead to serious complications if left untreated, including pelvic inflammatory disease (PID), infertility, and increased susceptibility to HIV. Treatment usually involves a dual antibiotic regimen to effectively eradicate the infection and prevent resistance. Contact tracing is crucial in managing gonococcal infections, as it helps identify and treat sexual partners to prevent reinfection and further transmission. Regular screening for STIs is recommended for sexually active individuals, particularly those with multiple partners or those who engage in unprotected sex.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation (asymptomatic vs symptomatic)
  • Need for accurate laboratory confirmation
  • Potential for co-infection with other STIs
  • Importance of thorough patient history and contact tracing

Audit Risk Factors

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

Specialty Focus

Medical Specialties

Obstetrics and Gynecology

Documentation Requirements

Detailed patient history, examination findings, laboratory results, and treatment plans.

Common Clinical Scenarios

Routine STI screening, management of symptomatic patients, and follow-up care.

Billing Considerations

Ensure documentation reflects the specific site of infection and any associated complications.

Infectious Disease

Documentation Requirements

Comprehensive documentation of diagnostic tests, treatment regimens, and patient follow-up.

Common Clinical Scenarios

Management of complicated gonococcal infections and co-infections with other STIs.

Billing Considerations

Focus on antibiotic resistance patterns and tailored treatment plans.

Coding Guidelines

Inclusion Criteria

Use A54.03 When
  • According to the official coding guidelines, A54
  • 03 should be used when the diagnosis of gonococcal cervicitis is confirmed but not specified further
  • Coders should ensure that documentation supports the diagnosis and that any associated conditions are coded appropriately

Exclusion Criteria

Do NOT use A54.03 When
No specific exclusions found.

Related CPT Codes

87491CPT Code

Nucleic acid amplification test for gonorrhea

Clinical Scenario

Used to confirm diagnosis of gonococcal cervicitis.

Documentation Requirements

Document the reason for testing and results.

Specialty Considerations

Ensure proper coding of the test based on the specialty performing it.

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 enhancing public health 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 enhancing public health tracking of STIs.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of gonococcal infections, improving data accuracy and enhancing public health tracking of STIs.

Resources

Clinical References

  • •
    CDC STI Treatment Guidelines

Coding & Billing References

  • •
    CDC STI Treatment Guidelines

Frequently Asked Questions

What are the common symptoms of gonococcal cervicitis?

Common symptoms include abnormal vaginal discharge, pelvic pain, and bleeding between periods. However, many individuals may be asymptomatic.

How is gonococcal cervicitis treated?

Treatment typically involves a dual antibiotic regimen to effectively eradicate the infection and prevent resistance.

Why is contact tracing important in gonococcal infections?

Contact tracing helps identify and treat sexual partners, preventing reinfection and further transmission of the infection.