ICD-10 Guide

A54.89

Other gonococcal infections

BILLABLE STATUSYes

IMPLEMENTATION DATEOctober 1, 2015

LAST UPDATED09/05/2025

Code Description

ICD-10 A54.89 is a billable code used to indicate a diagnosis of other gonococcal infections.

Key Diagnostic Point:

A54.89 refers to other gonococcal infections that are not classified under more specific codes. Gonococcal infections are caused by the bacterium Neisseria gonorrhoeae, which primarily affects the mucous membranes of the urogenital tract, but can also infect the rectum, throat, and conjunctiva. These infections are primarily transmitted through sexual contact, making them a significant concern in sexually transmitted infections (STIs). Symptoms may include dysuria, increased vaginal or penile discharge, and pelvic pain, but many individuals may be asymptomatic. The importance of contact tracing cannot be overstated, as it helps to identify and treat sexual partners to prevent further transmission. Treatment typically involves antibiotics, with dual therapy recommended to combat potential resistance. Regular screening and prompt treatment are essential in managing gonococcal infections and preventing complications such as pelvic inflammatory disease (PID) and infertility. Public health initiatives often focus on education, prevention strategies, and ensuring access to healthcare services for at-risk populations.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

Variability in clinical presentation and symptoms
Need for accurate documentation of sexual history
Differentiation from other STIs
Potential for co-infection with other pathogens

Audit Risk Factors

Inadequate documentation of symptoms
Failure to document sexual history
Lack of follow-up care documentation
Inconsistent coding of related STIs

Specialty Focus

Medical Specialties

Infectious Disease

Documentation Requirements

Detailed patient history, including sexual history and previous infections.

Common Clinical Scenarios

Management of recurrent gonococcal infections and treatment of co-infections.

Billing Considerations

Consideration of antibiotic resistance patterns and patient compliance with treatment.

Urology

Documentation Requirements

Documentation of urinary symptoms and any related complications.

Common Clinical Scenarios

Evaluation of male patients with urethritis and potential gonococcal infections.

Billing Considerations

Need for thorough examination to rule out other causes of urethritis.

Coding Guidelines

Inclusion Criteria

Use A54.89 When

According to ICD
10 coding guidelines, A54
89 should be used when the gonococcal infection does not fit into more specific categories
Coders should ensure that the documentation supports the diagnosis and that any related conditions are also coded appropriately

Exclusion Criteria

Do NOT use A54.89 When

No specific exclusions found.

Related CPT Codes

87491CPT Code

Gonorrhea test, amplified probe technique

Clinical Scenario

Used when testing for gonorrhea in symptomatic patients.

Documentation Requirements

Document the reason for testing and any symptoms present.

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. A54.89 provides a means to capture cases that do not fit into more defined categories.

ICD-9 vs ICD-10

Reimbursement & Billing Impact

Resources

Clinical References

•
CDC Gonorrhea Treatment Guidelines

Coding & Billing References

•
CDC Gonorrhea Treatment Guidelines

Frequently Asked Questions

When should I use A54.89 instead of more specific codes?

A54.89 should be used when the gonococcal infection does not fit into more specific categories, such as when the site of infection is not documented or when the infection is atypical.

ICD-10 A54.89 is a billable code used to indicate a diagnosis of other gonococcal infections.