ICD-10 Coding for Gonorrhea(A54.00, A54.02)
Complete ICD-10-CM coding and documentation guide for Gonorrhea. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Gonorrhea
A54Primary Range
Gonococcal infections
This range includes all gonococcal infections, covering various anatomical sites and complications.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| A54.00 | Gonococcal infection of lower genitourinary tract, unspecified | Use when the specific site of the lower genitourinary tract is not documented. |
|
| A54.02 | Gonococcal vulvovaginitis, unspecified | Use when gonococcal infection is confirmed in the vulva or vagina. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for gonorrhea
Essential facts and insights about Gonorrhea
Primary ICD-10-CM Codes for gonorrhea
Decision Criteria
clinical Criteria
- Confirmed gonococcal infection via laboratory testing
Applicable To
- Unspecified gonococcal infection of the lower genitourinary tract
Excludes
- Gonococcal infection of other sites
Clinical Validation Requirements
- Confirmed by NAAT or culture
- Presence of symptoms such as dysuria or discharge
Code-Specific Risks
- Risk of under-documentation if specific site is not identified
Coding Notes
- Ensure confirmation of diagnosis through laboratory testing before coding.
A54.02 - Gonococcal vulvovaginitis, unspecified
Use when gonococcal infection is confirmed in the vulva or vagina.
Applicable To
- Gonococcal infection of the vulva and vagina
Excludes
- Non-gonococcal vulvovaginitis
Clinical Validation Requirements
- Confirmed by NAAT or culture
- Symptoms such as vaginal discharge or irritation
Coding Notes
Document specific site and confirm with lab results.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Gonorrhea to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code A54.00.
Impact
Clinical: May lead to inappropriate treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Specify the organism in documentation., Use precise terminology like 'Neisseria gonorrhoeae identified'.
Impact
Reimbursement: Claims may be denied if not confirmed., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data reporting and analysis.
Mitigation Strategy
Ensure diagnosis is confirmed by NAAT or culture before coding.
Impact
High query rate for unspecified site codes.
Mitigation Strategy
Ensure documentation specifies the anatomical site of infection.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Gonorrhea, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Gonorrhea
Use these documentation templates to ensure complete and accurate documentation for Gonorrhea. These templates include all required elements for proper coding and billing.
Confirmed gonococcal infection with symptoms
Specialty: Infectious DiseaseRequired Elements
- Patient history
- Symptoms
- Lab results
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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