ICD-10 Coding for Dyspareunia(N94.11, N94.12)
Complete ICD-10-CM coding and documentation guide for Dyspareunia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Dyspareunia
N94.1-N94.19Primary Range
Dyspareunia
This range includes specific codes for different types of dyspareunia, such as superficial and deep.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N94.11 | Superficial dyspareunia | Use when pain is localized to the vaginal entrance and confirmed by clinical tests. |
|
| N94.12 | Deep dyspareunia | Use when pain is deep and associated with pelvic structures. |
|
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 superficial dyspareunia
Essential facts and insights about Dyspareunia
Primary ICD-10-CM Codes for dyspareunia
Decision Criteria
clinical Criteria
- Pain localized to vaginal introitus
Applicable To
- Introital pain during intercourse
Excludes
- Vaginismus (N94.2)
Clinical Validation Requirements
- Positive Q-tip test
- Pain localized to vaginal introitus
Code-Specific Risks
- Misclassification if pain is not superficial
Coding Notes
- Ensure pain is specifically documented as superficial.
N94.12 - Deep dyspareunia
Use when pain is deep and associated with pelvic structures.
Applicable To
- Deep pelvic pain during intercourse
Excludes
- Superficial dyspareunia (N94.11)
Clinical Validation Requirements
- Tenderness on uterosacral ligament palpation
- Laparoscopic confirmation of endometriosis
Coding Notes
Ensure pain is specifically documented as deep.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Dyspareunia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N94.11.
Impact
Clinical: May lead to inappropriate treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims.
Mitigation Strategy
Use specific terms and clinical findings., Include test results and pain characteristics.
Impact
Reimbursement: May lead to denied claims due to lack of specificity., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of health records.
Mitigation Strategy
Specify whether dyspareunia is superficial or deep.
Impact
Using unspecified codes like N94.1 can trigger audits.
Mitigation Strategy
Ensure documentation supports the most specific code.
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 Dyspareunia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Dyspareunia
Use these documentation templates to ensure complete and accurate documentation for Dyspareunia. These templates include all required elements for proper coding and billing.
Superficial dyspareunia in a gynecology clinic
Specialty: GynecologyRequired Elements
- Pain description
- Physical exam findings
- Associated conditions
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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