ICD-10 Guide

A54.1

Gonococcal infection of lower genitourinary tract, unspecified

BILLABLE STATUSYes

IMPLEMENTATION DATEOctober 1, 2015

LAST UPDATED09/05/2025

Code Description

ICD-10 A54.1 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 caused by the bacterium Neisseria gonorrhoeae, a sexually transmitted infection (STI) that primarily affects the urethra in men and the cervix in women. Symptoms may include dysuria, increased urinary frequency, and purulent discharge. In women, it can lead to pelvic inflammatory disease (PID) if left untreated, which can result in infertility. The infection can also be asymptomatic, particularly in women, making screening and early detection crucial. Gonococcal infections can be transmitted through sexual contact, including vaginal, anal, and oral sex. Contact tracing is essential to prevent further spread, as partners of infected individuals should be notified and tested. Treatment typically involves antibiotics, with dual therapy recommended to combat potential antibiotic resistance. The emergence of resistant strains of Neisseria gonorrhoeae has made adherence to treatment guidelines critical for effective management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

Variability in symptom presentation (asymptomatic cases)
Need for accurate patient history regarding sexual partners
Potential for co-infection with other STIs
Variations in treatment protocols based on local resistance patterns

Audit Risk Factors

Inadequate documentation of symptoms
Failure to document contact tracing efforts
Misclassification of the infection site
Lack of follow-up documentation

Specialty Focus

Medical Specialties

Infectious Disease

Documentation Requirements

Detailed patient history, including sexual history and symptoms, treatment plans, and follow-up care.

Common Clinical Scenarios

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

Billing Considerations

Consideration of local epidemiology and resistance patterns in treatment decisions.

Obstetrics and Gynecology

Documentation Requirements

Documentation of gynecological exams, symptoms, treatment plans, and patient education on STIs.

Common Clinical Scenarios

Screening and treatment of gonococcal infections in pregnant women, management of PID.

Billing Considerations

Importance of screening pregnant women and implications for neonatal health.

Coding Guidelines

Inclusion Criteria

Use A54.1 When

Follow the official ICD
CM coding guidelines, ensuring accurate documentation of the infection site and symptoms
Include any relevant patient history and treatment plans

Exclusion Criteria

Do NOT use A54.1 When

No specific exclusions found.

Related CPT Codes

87491CPT Code

Gonorrhea test, amplified probe technique

Clinical Scenario

Used when testing for gonococcal infection in symptomatic patients.

Documentation Requirements

Document the reason for testing and patient symptoms.

Specialty Considerations

Infectious disease specialists may require additional lab results.

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 and antibiotic resistance patterns.

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 and antibiotic resistance patterns.

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 and antibiotic resistance patterns.

Resources

Clinical References

•
CDC STI Treatment Guidelines

Coding & Billing References

•
CDC STI Treatment Guidelines

Frequently Asked Questions

What are the common symptoms of a gonococcal infection?

Common symptoms include dysuria, increased urinary frequency, and purulent discharge. However, many cases can be asymptomatic, especially in women.

ICD-10 A54.1 is a billable code used to indicate a diagnosis of gonococcal infection of lower genitourinary tract, unspecified.