ICD-10 Logo
ICDxICD-10 Medical Coding
ICD-10 Logo
ICDxICD-10 Medical Coding
ICD 10 CodesDiagnoses
ICD 10 CodesDiagnoses
ICD-10 Logo
ICDxICD-10 Medical Coding

Comprehensive ICD-10-CM code reference with AI-powered search capabilities.

© 2025 ICD Code Compass. All rights reserved.

Browse

  • All Chapters
  • All Categories
  • Diagnoses

Tools

  • AI Code Search
ICD-10-CM codes are maintained by the CDC and CMS. This tool is for reference purposes only.
v1.0.0
ICD-10 Guide
ICD-10 CodesA54.6

A54.6

Gonococcal infection of lower genitourinary tract, unspecified

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

Code Description

ICD-10 A54.6 is a billable code used to indicate a diagnosis of gonococcal infection of lower genitourinary tract, unspecified.

Key Diagnostic Point:

Gonococcal infection of the lower genitourinary tract is caused by the bacterium Neisseria gonorrhoeae, a sexually transmitted infection (STI) that primarily affects the urethra in men and the cervix in women. This infection can lead to a range of complications if left untreated, including pelvic inflammatory disease (PID) in women and epididymitis in men. Symptoms may include dysuria, increased urinary frequency, and purulent discharge. However, many individuals may be asymptomatic, particularly women, which complicates diagnosis and increases the risk of transmission. Gonococcal infections can also co-occur with other STIs, necessitating comprehensive screening and treatment. The unspecified designation indicates that the clinical documentation does not specify the exact site of infection within the lower genitourinary tract, which can affect treatment decisions and public health reporting. Effective management includes appropriate antibiotic therapy, patient education on safe sexual practices, and contact tracing to prevent further spread of the infection.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation (asymptomatic vs symptomatic)
  • Need for accurate documentation of symptoms and site of infection
  • Potential co-infection with other STIs
  • Variability in treatment protocols based on local guidelines

Audit Risk Factors

  • Inadequate documentation of symptoms
  • Failure to document patient education and counseling
  • Lack of follow-up care documentation
  • Inconsistent coding of co-infections

Specialty Focus

Medical Specialties

Infectious Disease

Documentation Requirements

Detailed patient history, symptomatology, and treatment plans.

Common Clinical Scenarios

Management of STIs, including gonococcal infections and co-infections.

Billing Considerations

Consideration of local epidemiology and resistance patterns in treatment.

Urology

Documentation Requirements

Urological examination findings, patient history, and treatment response.

Common Clinical Scenarios

Diagnosis and management of urethritis and related complications.

Billing Considerations

Documentation of any surgical interventions or complications.

Coding Guidelines

Inclusion Criteria

Use A54.6 When
  • According to ICD
  • 10 coding guidelines, A54
  • 6 should be used when the gonococcal infection is confirmed but the specific site is not documented
  • Coders should ensure that the diagnosis is supported by clinical documentation and that any related symptoms or complications are also coded appropriately

Exclusion Criteria

Do NOT use A54.6 When
No specific exclusions found.

Related CPT Codes

87491CPT Code

Nucleic acid amplification test for gonorrhea

Clinical Scenario

Used for confirming diagnosis of gonococcal infection.

Documentation Requirements

Document the reason for testing and results.

Specialty Considerations

Infectious disease specialists may require additional lab results.

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 public health tracking of STIs.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of gonococcal infections, improving data accuracy and facilitating better public health tracking of STIs.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of gonococcal infections, improving data accuracy and facilitating better public health tracking 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 gonococcal infection?

Common symptoms include dysuria, purulent discharge, and pelvic pain. However, many individuals may be asymptomatic.

How is gonococcal infection treated?

Treatment typically involves dual antibiotic therapy, often including ceftriaxone and azithromycin.

Why is contact tracing important for gonococcal infections?

Contact tracing helps to identify and treat sexual partners, reducing the spread of the infection.