Unspecified secondary syphilis

This code signifies a diagnosis of secondary syphilis where the specific manifestation (e.g., skin rash, mucocutaneous lesions, lymphadenopathy) is not documented. Secondary syphilis is a systemic stage of the infection, typically occurring weeks to months after the primary chancre, characterized by widespread dissemination of the Treponema pallidum spirochete.

Use this code when the medical record clearly indicates secondary syphilis, but lacks specific details about the clinical presentation or affected body systems. This code is appropriate when the provider's documentation states "secondary syphilis, unspecified" or similar. Documentation should confirm a positive serologic test for syphilis (e.g., RPR, VDRL, FTA-ABS) in conjunction with clinical signs consistent with the secondary stage, even if not fully elaborated.

• Avoid using this code if more specific documentation of secondary syphilis manifestations (e.g., syphilitic rash, condyloma lata) is available.
• Always look for documentation of the specific type of secondary syphilis to allow for more precise coding (e.g., 091.3 for secondary syphilis of skin and mucous membranes).
• Ensure documentation supports the secondary stage of syphilis, differentiating it from primary (091.0) or latent (092.x) stages.