ICD-10 Coding for Neurosyphilis(A52.1, A52.2, A52.3)
Complete ICD-10-CM coding and documentation guide for Neurosyphilis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Neurosyphilis
A52.0-A52.9Primary Range
Late syphilis with clinical manifestations
This range includes all forms of late syphilis, including neurosyphilis, which is a critical aspect of syphilitic infections affecting the nervous system.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| A52.1 | Symptomatic neurosyphilis | Use when specific symptoms of neurosyphilis are documented, such as dementia or ataxia. |
|
| A52.2 | Asymptomatic neurosyphilis | Use when CSF abnormalities are present but no neurological symptoms are documented. |
|
| A52.3 | Unspecified neurosyphilis | Use only when specific details are unavailable and cannot be obtained. |
|
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 symptomatic neurosyphilis
Essential facts and insights about Neurosyphilis
Primary ICD-10-CM Codes for neurosyphilis
Decision Criteria
clinical Criteria
- Presence of neurological symptoms like ataxia or dementia.
Applicable To
- Tabes dorsalis
- General paresis
- Charcot joint
Excludes
- Asymptomatic neurosyphilis (A52.2)
Clinical Validation Requirements
- CSF-VDRL reactive
- MRI showing frontotemporal atrophy
- Symptoms like dementia, ataxia
Code-Specific Risks
- Misclassification if symptoms are not clearly documented.
Coding Notes
- Ensure documentation specifies the subtype of symptomatic neurosyphilis.
A52.2 - Asymptomatic neurosyphilis
Use when CSF abnormalities are present but no neurological symptoms are documented.
Applicable To
- CSF abnormalities without symptoms
Excludes
- Symptomatic neurosyphilis (A52.1)
Clinical Validation Requirements
- CSF-VDRL reactive
- Elevated CSF protein
- Pleocytosis
Coding Notes
Ensure CSF findings are clearly documented.
A52.3 - Unspecified neurosyphilis
Use only when specific details are unavailable and cannot be obtained.
Excludes
- Symptomatic neurosyphilis (A52.1)
- Asymptomatic neurosyphilis (A52.2)
Clinical Validation Requirements
- Lack of specific symptoms or CSF findings
Coding Notes
Avoid using unless absolutely necessary.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
HIV disease
B20Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Neurosyphilis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code A52.1.
Impact
Clinical: May lead to misdiagnosis or inappropriate treatment., Regulatory: Increases risk of audit and compliance issues., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Ensure detailed documentation of neurological symptoms., Include all relevant test results in the patient's record.
Impact
Reimbursement: May lead to lower reimbursement if unspecified code is used., Compliance: Increases audit risk due to lack of specificity., Data Quality: Reduces data accuracy and quality.
Mitigation Strategy
Ensure specific symptoms or CSF findings are documented to use A52.1 or A52.2.
Impact
High audit risk when using A52.3 without justification.
Mitigation Strategy
Ensure specific documentation is available to support the use of A52.1 or A52.2.
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 Neurosyphilis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Neurosyphilis
Use these documentation templates to ensure complete and accurate documentation for Neurosyphilis. These templates include all required elements for proper coding and billing.
Neurology H&P
Specialty: NeurologyRequired Elements
- History of syphilis
- Neurological exam details
- CSF findings
- Imaging results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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