ICD-10-CM Billable Code

A54.09

Other gonococcal infection of lower genitourinary tract

Clinical Classification Guidelines

Medical Intelligence & Overview

Gonococcal infections are caused by the bacteria *Neisseria gonorrhoeae* and are among the most common sexually transmitted infections (STIs). When these infections affect the lower part of the genitourinary tract, they can lead to discomfort and other health complications. ICD-10 code A54.09 specifically refers to other gonococcal infections originating in the lower genitourinary region, which may include areas such as the urethra, cervix, and surrounding structures. Recognizing and understanding this condition is important for obtaining proper diagnosis and treatment.

Causes & Symptoms

Clinical Causes: Unprotected sexual contact with an infected partner Sharing of contaminated sex toys Mother to child transmission during childbirth (less common for lower genitourinary tract infections) Presence of underlying sexually transmitted infections that increase susceptibility

Key Symptoms: Pain or a burning sensation during urination Unusual genital discharge (such as thick, yellow or greenish pus) Pain or bleeding in the lower abdomen or pelvis Swelling or redness in the affected area Itching or discomfort in the genital region Sometimes, no symptoms are present, especially in women

Diagnostic & Treatment

Diagnosis Path: Diagnosing a gonococcal infection involves a combination of medical history, physical examination, and laboratory testing. Common diagnostic methods include:

Treatment Protocols: Effective treatment of gonococcal infections typically involves antibiotics. It is important to follow a healthcare provider’s recommendations for medication. Common treatment options include:

Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.

Clinical Advice & FAQs

Billing Guidance

Is A54.09 a billable ICD-10 code?
Yes, A54.09 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report A54.09?
Clinical documentation must specify the nature of Other gonococcal infection of lower genitourinary tract and any associated comorbidities for accurate reporting.

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