ICD-10 Coding for Vaginal Candida(B37.31, B37.32)
Complete ICD-10-CM coding and documentation guide for Vaginal Candida. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Vaginal Candida
B37.3-B37.32Primary Range
Candidiasis of Vulva and Vagina
This range includes codes for acute and chronic vulvovaginal candidiasis, which are the primary conditions being documented.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| B37.31 | Acute candidiasis of vulva and vagina | Use for acute cases with less than 3 episodes per year in a normal host with confirmed C. albicans. |
|
| B37.32 | Chronic candidiasis of vulva and vagina | Use for chronic cases with ≥4 episodes per year or in immunocompromised hosts. |
|
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 vaginal candida
Essential facts and insights about Vaginal Candida
Primary ICD-10-CM Codes for vaginal candida
Decision Criteria
clinical Criteria
- Presence of acute symptoms and positive KOH test
documentation Criteria
- Documentation of less than 3 episodes per year
Applicable To
- Acute vulvovaginal candidiasis
Excludes
- Chronic vulvovaginal candidiasis (B37.32)
Clinical Validation Requirements
- Symptoms: External dysuria, vulvar pruritus/erythema
- Exam Findings: Thick, curdy discharge
- Diagnostic Proof: 10% KOH wet mount positive for pseudohyphae
Code-Specific Risks
- Misclassification as chronic if recurrence criteria are not met.
Coding Notes
- Ensure documentation specifies acute nature and confirms Candida species.
B37.32 - Chronic candidiasis of vulva and vagina
Use for chronic cases with ≥4 episodes per year or in immunocompromised hosts.
Applicable To
- Chronic vulvovaginal candidiasis
Excludes
- Acute vulvovaginal candidiasis (B37.31)
Clinical Validation Requirements
- Recurrent episodes: ≥4 per year
- Immunocompromised host or non-albicans species
- Diagnostic Proof: Culture confirms non-albicans species
Coding Notes
Ensure documentation specifies chronic nature and confirms recurrent episodes.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Other specified bacterial agents as the cause of diseases classified elsewhere
B96.89Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Vaginal Candida to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code B37.31.
Impact
Clinical: May lead to inappropriate treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Use specific terms and include lab results., Document detailed clinical findings.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Inaccurate clinical data and patient records.
Mitigation Strategy
Use B37.31 or B37.32 based on acute or chronic presentation.
Impact
Failure to document specific Candida species can lead to audit issues.
Mitigation Strategy
Ensure lab results are included in documentation.
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 Vaginal Candida, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Vaginal Candida
Use these documentation templates to ensure complete and accurate documentation for Vaginal Candida. These templates include all required elements for proper coding and billing.
Recurrent Vulvovaginal Candidiasis
Specialty: OB-GYNRequired Elements
- Chief complaint
- History of present illness
- Physical exam findings
- Lab results
- Assessment and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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