ICD-10 Coding for Vaginal Discharge(N76.0, B37.3, A59.01)
Complete ICD-10-CM coding and documentation guide for Vaginal Discharge. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Vaginal Discharge
N76-N89Primary Range
Diseases of the female genital organs
This range includes codes for various conditions affecting the female genital organs, including vaginitis and leukorrhea.
Candidiasis
This range includes codes for fungal infections such as candidiasis, which can cause vaginal discharge.
Trichomoniasis
This range includes codes for trichomoniasis, a sexually transmitted infection that can cause vaginal discharge.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N76.0 | Acute vaginitis | Use when clinical criteria for bacterial vaginosis are met. |
|
| B37.3 | Candidiasis of vulva and vagina | Use when candidiasis is confirmed by lab tests. |
|
| A59.01 | Trichomonal vulvovaginitis | Use when trichomoniasis is confirmed by lab tests. |
|
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 bacterial vaginosis
Essential facts and insights about Vaginal Discharge
Primary ICD-10-CM Codes for vaginal discharge
Decision Criteria
clinical Criteria
- Presence of clue cells and positive whiff test
Clinical Validation Requirements
- pH >4.5
- Positive whiff test
- Presence of clue cells on wet mount
Code-Specific Risks
- Incorrectly using without confirming infection
- Missing additional infectious agent codes
Coding Notes
- Ensure documentation supports the presence of infection.
B37.3 - Candidiasis of vulva and vagina
Use when candidiasis is confirmed by lab tests.
Applicable To
- Yeast infection
Excludes
- Trichomoniasis (A59.01)
Clinical Validation Requirements
- Thick white discharge
- Presence of pseudohyphae on KOH prep
Coding Notes
Ensure lab confirmation of candidiasis.
A59.01 - Trichomonal vulvovaginitis
Use when trichomoniasis is confirmed by lab tests.
Applicable To
- Trichomoniasis
Excludes
- Candidiasis (B37.3)
Clinical Validation Requirements
- Frothy yellow-green discharge
- Motile trichomonads on saline mount
Coding Notes
Ensure lab confirmation of trichomoniasis.
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
B96.89Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Vaginal Discharge to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N76.0.
Impact
Clinical: Leads to misdiagnosis., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Ensure lab results are included in the patient's record.
Impact
Reimbursement: May lead to denied claims if infection is not documented., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data reporting.
Mitigation Strategy
Ensure clinical criteria for infection are documented.
Impact
Risk of audits due to insufficient documentation of clinical criteria.
Mitigation Strategy
Use templates to ensure all criteria are documented.
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 Discharge, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Vaginal Discharge
Use these documentation templates to ensure complete and accurate documentation for Vaginal Discharge. These templates include all required elements for proper coding and billing.
Patient with suspected bacterial vaginosis
Specialty: OB/GYNRequired Elements
- Chief Complaint
- Discharge characteristics
- Associated symptoms
- Lab findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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