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ICD-10 Guide
ICD-10 CodesA54.21

A54.21

Gonococcal infection of kidney and ureter

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

Code Description

ICD-10 A54.21 is a billable code used to indicate a diagnosis of gonococcal infection of kidney and ureter.

Key Diagnostic Point:

Gonococcal infection of the kidney and ureter is a serious sexually transmitted infection caused by the bacterium Neisseria gonorrhoeae. This infection can ascend from the lower urinary tract, typically starting in the urethra, and can lead to pyelonephritis, which is an infection of the kidney. Symptoms may include flank pain, fever, dysuria, and increased urinary frequency. In some cases, the infection may be asymptomatic, making it crucial for sexually active individuals to undergo regular screening. Diagnosis is typically confirmed through urine tests or cultures. Treatment involves the use of appropriate antibiotics, with dual therapy often recommended to ensure eradication of the infection and to combat potential antibiotic resistance. Contact tracing is essential to prevent reinfection and further spread of the disease, as gonorrhea is highly contagious. Patients should be educated on safe sex practices and the importance of notifying sexual partners for testing and treatment.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Requires understanding of sexually transmitted infections (STIs)
  • Differentiation from other urinary tract infections (UTIs)
  • Need for accurate documentation of symptoms and treatment
  • Potential for co-infection with other STIs

Audit Risk Factors

  • Inadequate documentation of sexual history
  • Failure to document treatment regimen
  • Lack of follow-up notes on patient outcomes
  • Misclassification of the infection type

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

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

Common Clinical Scenarios

Patients presenting with flank pain, dysuria, or recurrent UTIs.

Billing Considerations

Urologists should ensure that all relevant tests and treatments are documented to support the diagnosis.

Infectious Disease

Documentation Requirements

Comprehensive documentation of laboratory results, treatment protocols, and patient education on STIs.

Common Clinical Scenarios

Patients with confirmed gonococcal infections requiring specialized treatment and follow-up.

Billing Considerations

Infectious disease specialists should document any co-infections and resistance patterns.

Coding Guidelines

Inclusion Criteria

Use A54.21 When
  • According to the official coding guidelines, A54
  • 21 should be used when there is a confirmed diagnosis of gonococcal infection affecting the kidney and ureter
  • It is important to document the specific site of infection and any associated symptoms

Exclusion Criteria

Do NOT use A54.21 When
  • Exclusion criteria include infections caused by other organisms

Related CPT Codes

87591CPT Code

Nucleic acid amplification test for gonorrhea

Clinical Scenario

Used when testing for gonococcal infection in symptomatic patients.

Documentation Requirements

Document the reason for testing and patient symptoms.

Specialty Considerations

Urologists and infectious disease specialists should ensure that testing aligns with clinical findings.

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 the accuracy of data collection and treatment tracking. This specificity aids in better understanding the epidemiology of STIs and enhances public health responses.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of gonococcal infections, improving the accuracy of data collection and treatment tracking. This specificity aids in better understanding the epidemiology of STIs and enhances public health responses.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of gonococcal infections, improving the accuracy of data collection and treatment tracking. This specificity aids in better understanding the epidemiology of STIs and enhances public health responses.

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 of the kidney?

Common symptoms include flank pain, fever, dysuria, and increased urinary frequency. Some patients may be asymptomatic.