Chlamydia trachomatis infection
ICD-10 A56 is a billable code used to indicate a diagnosis of chlamydia trachomatis infection.
Chlamydia trachomatis infection is a sexually transmitted infection (STI) caused by the bacterium Chlamydia trachomatis. It is one of the most common STIs worldwide and can affect both men and women. In women, it can lead to pelvic inflammatory disease (PID), infertility, and ectopic pregnancy if left untreated. In men, it may cause urethritis and epididymitis. Many individuals infected with Chlamydia are asymptomatic, which complicates diagnosis and increases the risk of transmission. Symptoms, when present, may include abnormal genital discharge, burning sensation during urination, and abdominal pain. Diagnosis is typically made through nucleic acid amplification tests (NAATs) or other laboratory tests. Treatment usually involves antibiotics, such as azithromycin or doxycycline, and it is crucial to treat sexual partners to prevent reinfection and further spread of the disease. Regular screening is recommended for sexually active individuals, particularly those under 25 years of age or with multiple sexual partners.
Detailed patient history, including sexual history and previous STIs.
Diagnosis and management of symptomatic and asymptomatic Chlamydia infections.
Ensure documentation includes all relevant tests and treatments, especially for asymptomatic patients.
Documentation of pelvic exams, lab results, and treatment plans.
Routine screening and treatment of Chlamydia in sexually active women.
Document any complications such as PID or infertility to support coding.
Used during routine STI screening or when symptoms are present.
Document the reason for testing and results.
Infectious disease specialists should ensure comprehensive STI panels are ordered.
The primary treatment for Chlamydia trachomatis infection is antibiotics, typically azithromycin or doxycycline, depending on the patient's medical history and any potential allergies.
