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ICD-10 Guide
ICD-10 CodesA56.1

A56.1

Chlamydial infection of lower genitourinary tract, unspecified

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

Code Description

ICD-10 A56.1 is a billable code used to indicate a diagnosis of chlamydial infection of lower genitourinary tract, unspecified.

Key Diagnostic Point:

Chlamydial infection of the lower genitourinary tract is a common sexually transmitted infection (STI) caused by the bacterium Chlamydia trachomatis. This infection primarily affects the urethra in men and the cervix in women, leading to symptoms such as dysuria, increased urinary frequency, and abnormal vaginal discharge. However, many individuals remain asymptomatic, which complicates diagnosis and increases the risk of transmission. The infection can lead to serious complications if left untreated, including pelvic inflammatory disease (PID) in women, which can result in infertility. Diagnosis is typically made through nucleic acid amplification tests (NAATs), which are highly sensitive and specific. Treatment usually involves a course of antibiotics, such as azithromycin or doxycycline. Contact tracing is crucial in managing chlamydial infections, as it helps identify and 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 those with multiple sexual partners.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in symptoms and asymptomatic cases complicating diagnosis.
  • Need for accurate patient history to determine risk factors.
  • Potential for co-infection with other STIs, requiring careful documentation.
  • Variability in treatment protocols based on patient demographics and clinical guidelines.

Audit Risk Factors

  • Inadequate documentation of patient history and risk factors.
  • Failure to document treatment plans and follow-up care.
  • Lack of evidence for contact tracing efforts.
  • Misclassification of the infection as another STI.

Specialty Focus

Medical Specialties

Infectious Disease

Documentation Requirements

Detailed patient history, including sexual history and previous STIs.

Common Clinical Scenarios

Diagnosis and management of STIs, particularly in high-risk populations.

Billing Considerations

Consideration of co-infections and the need for comprehensive treatment plans.

Obstetrics and Gynecology

Documentation Requirements

Documentation of gynecological exams, symptoms, and treatment plans.

Common Clinical Scenarios

Routine screening and management of STIs in pregnant women.

Billing Considerations

Impact of chlamydia on pregnancy outcomes and the need for partner notification.

Coding Guidelines

Inclusion Criteria

Use A56.1 When
  • According to the official coding guidelines, A56
  • 1 should be used when the chlamydial infection is confirmed but not specified further
  • Coders should ensure that the diagnosis is supported by appropriate clinical documentation and that any related conditions are also coded

Exclusion Criteria

Do NOT use A56.1 When
No specific exclusions found.

Related CPT Codes

87491CPT Code

Chlamydia trachomatis, amplified probe technique

Clinical Scenario

Used for testing in patients suspected of having chlamydial infection.

Documentation Requirements

Document the reason for testing and patient consent.

Specialty Considerations

Infectious disease specialists may require additional lab results for comprehensive management.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of chlamydial infections, improving data accuracy and facilitating better tracking of STIs. A56.1 provides a clear designation for unspecified lower genitourinary tract infections, aiding in epidemiological studies and public health initiatives.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of chlamydial infections, improving data accuracy and facilitating better tracking of STIs. A56.1 provides a clear designation for unspecified lower genitourinary tract infections, aiding in epidemiological studies and public health initiatives.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of chlamydial infections, improving data accuracy and facilitating better tracking of STIs. A56.1 provides a clear designation for unspecified lower genitourinary tract infections, aiding in epidemiological studies and public health initiatives.

Resources

Clinical References

  • •
    CDC Chlamydia Fact Sheet

Coding & Billing References

  • •
    CDC Chlamydia Fact Sheet

Frequently Asked Questions

What are the common symptoms of chlamydial infection?

Common symptoms include dysuria, abnormal discharge, and pelvic pain, but many individuals may be asymptomatic.

How is chlamydia treated?

Chlamydia is typically treated with antibiotics such as azithromycin or doxycycline.

Why is contact tracing important?

Contact tracing helps identify and treat sexual partners, reducing the risk of reinfection and further transmission.