ICD-10 Coding for Vaginal Discomfort(N76.0, N94.1, R10.2)
Complete ICD-10-CM coding and documentation guide for Vaginal Discomfort. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Vaginal Discomfort
N76.0-N76.3Primary Range
Inflammatory diseases of the vagina and vulva
These codes cover conditions like vaginitis and vulvovaginitis, which are common causes of vaginal discomfort.
Dyspareunia
This code is used for pain during intercourse, a specific type of vaginal discomfort.
Pelvic and perineal pain
This code is used when vaginal discomfort is part of a broader pelvic pain syndrome.
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 there is an acute infection causing vaginal discomfort. |
|
| N94.1 | Dyspareunia | Use for pain specifically associated with intercourse. |
|
| R10.2 | Pelvic and perineal pain | Use when pain is part of a broader pelvic pain syndrome. |
|
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 discomfort
Essential facts and insights about Vaginal Discomfort
Primary ICD-10-CM Codes for vaginal discomfort
Decision Criteria
clinical Criteria
- Presence of acute symptoms and lab-confirmed infection
Applicable To
- Purulent discharge
- Lab-confirmed infection
Excludes
- Chronic vaginitis (N76.1)
Clinical Validation Requirements
- Purulent discharge
- Positive culture for infection
Code-Specific Risks
- Misclassification if chronic symptoms are present
Coding Notes
- Ensure lab confirmation of infection before coding.
N94.1 - Dyspareunia
Use for pain specifically associated with intercourse.
Applicable To
- Pain during intercourse
Excludes
- Vaginismus (N94.2)
Clinical Validation Requirements
- Pain mapping
- Q-tip test documentation
Coding Notes
Document specific pain characteristics and location.
R10.2 - Pelvic and perineal pain
Use when pain is part of a broader pelvic pain syndrome.
Applicable To
- Diffuse pelvic pain
Excludes
- Localized vaginal pain (N94.1)
Clinical Validation Requirements
- Pelvic exam noting tenderness in multiple quadrants
Coding Notes
Ensure documentation specifies the broader pain context.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Candidiasis of vulva and vagina
B37.3Differential 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 Discomfort to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N76.0.
Impact
Clinical: May lead to misdiagnosis., Regulatory: Increases risk of audit issues., Financial: Potential for denied claims.
Mitigation Strategy
Use specific descriptors for symptoms., Include detailed exam findings.
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Increases risk of audit failures., Data Quality: Decreases accuracy of health data.
Mitigation Strategy
Always document specific symptoms and use the most precise code.
Impact
Unspecified codes can trigger audits due to lack of specificity.
Mitigation Strategy
Ensure documentation supports the most specific code possible.
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 Discomfort, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Vaginal Discomfort
Use these documentation templates to ensure complete and accurate documentation for Vaginal Discomfort. These templates include all required elements for proper coding and billing.
Patient presenting with vaginal discomfort
Specialty: GynecologyRequired Elements
- Pain description
- Location specificity
- Temporal pattern
- Associated findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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