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ICD-10 Guide
ICD-10 CodesA54.09

A54.09

Other gonococcal infection of lower genitourinary tract

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

Code Description

ICD-10 A54.09 is a billable code used to indicate a diagnosis of other gonococcal infection of lower genitourinary tract.

Key Diagnostic Point:

A54.09 refers to other gonococcal infections affecting the lower genitourinary tract, which includes conditions such as gonococcal urethritis and cervicitis. These infections are caused by the bacterium Neisseria gonorrhoeae, a common sexually transmitted infection (STI). Symptoms may include dysuria, increased urinary frequency, purulent discharge, and pelvic pain. In women, it can lead to cervicitis, which may present with abnormal vaginal discharge and bleeding. If left untreated, gonococcal infections can result in serious complications, including pelvic inflammatory disease (PID) in women and epididymitis in men. The diagnosis is typically confirmed through laboratory testing, including nucleic acid amplification tests (NAATs) or culture. Treatment usually involves antibiotics, with dual therapy recommended to combat potential resistance. Contact tracing is crucial to prevent reinfection and further transmission, emphasizing the importance of notifying sexual partners. Public health guidelines recommend routine screening for at-risk populations, including sexually active adolescents and young adults.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of symptoms that may overlap with other conditions
  • Need for accurate laboratory confirmation
  • Potential for co-infections with other STIs
  • Variability in treatment protocols based on resistance patterns

Audit Risk Factors

  • Inadequate documentation of symptoms and laboratory results
  • Failure to document patient education on STI prevention
  • Lack of follow-up care notes
  • Insufficient detail on contact tracing efforts

Specialty Focus

Medical Specialties

Infectious Disease

Documentation Requirements

Detailed patient history, laboratory results, treatment plans, and follow-up notes.

Common Clinical Scenarios

Management of patients with recurrent gonococcal infections or those with co-infections.

Billing Considerations

Consideration of antibiotic resistance patterns and patient adherence to treatment.

Urology

Documentation Requirements

Clinical findings, diagnostic imaging if applicable, and treatment protocols.

Common Clinical Scenarios

Evaluation of male patients presenting with urethritis or epididymitis.

Billing Considerations

Differentiating between gonococcal and non-gonococcal urethritis.

Coding Guidelines

Inclusion Criteria

Use A54.09 When
  • According to ICD
  • 10 coding guidelines, A54
  • 09 should be used when the gonococcal infection is specifically identified as affecting the lower genitourinary tract
  • It is important to document the specific site of infection and any associated symptoms

Exclusion Criteria

Do NOT use A54.09 When
  • Exclusion criteria include infections that are not confirmed as gonococcal or those affecting other anatomical sites

Related CPT Codes

87491CPT Code

Nucleic acid amplification test for gonorrhea

Clinical Scenario

Used for confirming a diagnosis of gonococcal infection.

Documentation Requirements

Document the reason for testing and patient consent.

Specialty Considerations

Infectious disease specialists may require additional details 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. A54.09 provides a more precise classification compared to previous ICD-9 codes.

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. A54.09 provides a more precise classification compared to previous ICD-9 codes.

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. A54.09 provides a more precise classification compared to previous ICD-9 codes.

Resources

Clinical References

  • •
    CDC Gonorrhea Treatment Guidelines

Coding & Billing References

  • •
    CDC Gonorrhea Treatment Guidelines

Frequently Asked Questions

What are the common symptoms of a gonococcal infection?

Common symptoms include dysuria, purulent discharge, and pelvic pain. Women may also experience abnormal vaginal bleeding.

How is a gonococcal infection diagnosed?

Diagnosis is typically made through laboratory testing, including NAATs or culture, alongside clinical evaluation.

What is the recommended treatment for gonococcal infections?

The CDC recommends dual therapy with ceftriaxone and azithromycin to effectively treat gonococcal infections.