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ICD-10 Guide
ICD-10 CodesA54.23

A54.23

Gonococcal infection of other male genital organs

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

Code Description

ICD-10 A54.23 is a billable code used to indicate a diagnosis of gonococcal infection of other male genital organs.

Key Diagnostic Point:

Gonococcal infection of other male genital organs refers to the infection caused by the bacterium Neisseria gonorrhoeae, which primarily affects the urethra but can also involve other male genital structures such as the epididymis, prostate, and seminal vesicles. This sexually transmitted infection (STI) is characterized by symptoms such as urethral discharge, dysuria, and in some cases, pain or swelling in the affected areas. If left untreated, gonococcal infections can lead to serious complications, including infertility, epididymitis, and disseminated gonococcal infection (DGI), which can affect joints and skin. Diagnosis is typically made through laboratory testing, including nucleic acid amplification tests (NAATs) or culture methods. Treatment usually involves antibiotics, with dual therapy recommended to combat potential antibiotic resistance. Contact tracing is crucial to prevent further transmission, as asymptomatic individuals can unknowingly spread the infection. Regular screening and education about safe sexual practices are essential components of managing gonococcal infections.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between various sites of gonococcal infection.
  • Understanding the nuances of related codes for other STIs.
  • Documentation requirements for confirming the diagnosis.
  • Potential for co-infection with other STIs, complicating coding.

Audit Risk Factors

  • Inadequate documentation of the specific site of infection.
  • Failure to document treatment plans or follow-up care.
  • Lack of patient history regarding sexual partners.
  • Misclassification of the infection site leading to incorrect coding.

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed notes on the patient's symptoms, examination findings, and any diagnostic tests performed.

Common Clinical Scenarios

Patients presenting with dysuria, urethral discharge, or scrotal pain.

Billing Considerations

Urologists should ensure that all relevant symptoms and examination findings are documented to support the diagnosis.

Infectious Disease

Documentation Requirements

Comprehensive patient history, including sexual history and previous STI infections.

Common Clinical Scenarios

Patients with recurrent STIs or those presenting with systemic symptoms.

Billing Considerations

Infectious disease specialists should document the rationale for testing and treatment choices.

Coding Guidelines

Inclusion Criteria

Use A54.23 When
  • According to the ICD
  • CM coding guidelines, A54
  • 23 should be used when the gonococcal infection specifically involves other male genital organs
  • Coders must ensure that the diagnosis is supported by clinical documentation and that any related conditions are also coded appropriately

Exclusion Criteria

Do NOT use A54.23 When
  • Exclusion criteria include infections that are not caused by Neisseria gonorrhoeae

Related CPT Codes

87491CPT Code

Nucleic acid amplification test (NAAT) for gonorrhea

Clinical Scenario

Used for diagnosing gonococcal infections in symptomatic patients.

Documentation Requirements

Document the reason for testing and any relevant patient history.

Specialty Considerations

Urologists and infectious disease specialists should ensure comprehensive documentation to support the necessity of the test.

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, enabling better tracking of infection sites and treatment outcomes. This specificity aids in public health reporting and management of STIs.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of gonococcal infections, enabling better tracking of infection sites and treatment outcomes. This specificity aids in public health reporting and management of STIs.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of gonococcal infections, enabling better tracking of infection sites and treatment outcomes. This specificity aids in public health reporting and management of STIs.

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, urethral discharge, and pain in the genital area. Some individuals may be asymptomatic.

How is a gonococcal infection diagnosed?

Diagnosis is typically made through laboratory tests, including nucleic acid amplification tests (NAATs) or cultures.

What is the recommended treatment for gonococcal infections?

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

Why is contact tracing important for gonococcal infections?

Contact tracing helps identify and treat sexual partners to prevent further transmission of the infection.