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BETA v.3.0

2025 ICD-10-CM code A54

Gonococcal infection, unspecified.

Use additional code to identify resistance to antimicrobial drugs (Z16.-). Do not use A54 with codes for specific gonococcal infections (A50-A53, A55-A59).

Medical necessity for treatment is established by a positive laboratory test for N. gonorrhoeae or strong clinical suspicion based on symptoms and risk factors. Treatment is necessary to prevent complications such as PID, infertility, and DGI.

Diagnosis and treatment of gonococcal infection involves physical examination, laboratory tests (cultures, DNA probe, PCR, LCR), and antibiotic therapy (typically ceftriaxone with azithromycin or doxycycline).

In simple words: This code indicates a gonorrhea infection, a sexually transmitted disease. It can affect different parts of the body, including the genitals, rectum, throat, and can sometimes spread through the bloodstream causing more serious problems.

This code encompasses any gonococcal infection not otherwise specified, including infections of the genitals, rectum, pharynx, and disseminated gonococcal infection (DGI).

Example 1: A 25-year-old male presents with dysuria and urethral discharge.A urethral swab is positive for N. gonorrhoeae., A 30-year-old female is asymptomatic but tested for STIs during a routine gynecological exam. A cervical culture is positive for N. gonorrhoeae., A 20-year-old patient presents with fever, joint pain, and a rash. Blood cultures and joint fluid analysis confirm disseminated gonococcal infection.

Documentation should include the site of infection, signs and symptoms, laboratory results confirming the diagnosis, and treatment plan.

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