Early syphilis, latent, serological relapse after treatment

This code signifies a stage of syphilis where the patient has no active symptoms but serological tests indicate a recurrence of the infection following previous treatment. It specifically points to an early stage of latency, meaning the infection was acquired within the past year. The relapse is confirmed by serological markers, indicating the treatment was not fully effective or reinfection occurred.

Apply this code when documentation confirms a patient has previously been treated for syphilis, but subsequent serological testing (e.g., RPR, VDRL titers) shows a significant increase, indicating a serological relapse. This is applicable when the initial infection is considered early (within the past 12 months) and the patient remains asymptomatic. Documentation should clearly state "latent syphilis," "early," and "serological relapse after treatment."

• Ensure documentation specifies "early" latent syphilis; otherwise, consider codes for late or unspecified latent syphilis.
• This code is for serological relapse, not clinical relapse with active lesions.
• Sequence this code as the primary diagnosis when the serological relapse is the reason for the encounter.