ICD-10 Coding for Vaginitis(N76.0, N76.1, A59.01, B37.3)
Complete ICD-10-CM coding and documentation guide for Vaginitis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Vaginitis
N76.0-N76.9Primary Range
Inflammatory diseases of female pelvic organs
This range includes codes for various types of vaginitis, including bacterial, candidal, and trichomonal infections.
Trichomoniasis
This range includes codes for trichomonal infections, which can present similarly to vaginitis.
Candidal vulvovaginitis
This code is used for candidal infections of the vulva and vagina, a common differential diagnosis for vaginitis.
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 for acute bacterial vaginosis when clinical criteria such as Amsel criteria are met. |
|
| N76.1 | Subacute and chronic vaginitis | Use for chronic or subacute presentations of vaginitis. |
|
| A59.01 | Trichomonal vulvovaginitis | Use when trichomoniasis is confirmed via laboratory testing. |
|
| B37.3 | Candidal vulvovaginitis | Use when candidal infection is confirmed via laboratory testing. |
|
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 Vaginitis
Primary ICD-10-CM Codes for vaginitis
Decision Criteria
clinical Criteria
- Presence of Amsel criteria
documentation Criteria
- Detailed description of discharge and test results
Clinical Validation Requirements
- Fishy odor
- Clue cells on wet mount
- pH >4.5
- Positive whiff test
Code-Specific Risks
- Misclassification if specific organism is identified
Coding Notes
- Ensure documentation supports acute presentation and includes specific clinical findings.
N76.1 - Subacute and chronic vaginitis
Use for chronic or subacute presentations of vaginitis.
Applicable To
- Chronic bacterial vaginosis
Excludes
- Acute vaginitis (N76.0)
Clinical Validation Requirements
- Symptoms persisting for more than 6 weeks
- Recurrent episodes
Coding Notes
Document chronicity and any recurrent treatment failures.
A59.01 - Trichomonal vulvovaginitis
Use when trichomoniasis is confirmed via laboratory testing.
Applicable To
- Trichomoniasis
Excludes
- Bacterial vaginosis (N76.0)
- Candidal vaginitis (B37.3)
Clinical Validation Requirements
- Frothy yellow discharge
- Motile trichomonads on wet mount
- PCR positive for T. vaginalis
Coding Notes
Ensure lab confirmation of trichomoniasis.
B37.3 - Candidal vulvovaginitis
Use when candidal infection is confirmed via laboratory testing.
Applicable To
- Yeast infection
Excludes
- Bacterial vaginosis (N76.0)
- Trichomonal vaginitis (A59.01)
Clinical Validation Requirements
- Cottage-cheese discharge
- Pseudohyphae on KOH prep
- PCR positive for Candida species
Coding Notes
Document specific findings supporting candidal infection.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential 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 Vaginitis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N76.0.
Impact
Clinical: Inaccurate diagnosis and treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Ensure all lab results are included in documentation.
Impact
Reimbursement: Incorrect coding may lead to claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Code B37.3 and document discharge and KOH findings.
Impact
Reimbursement: Potential underpayment for services., Compliance: Failure to comply with coding specificity., Data Quality: Incomplete clinical data.
Mitigation Strategy
Add B96.89 for identified bacterial agents.
Impact
Failure to document Amsel criteria can lead to audit issues.
Mitigation Strategy
Ensure all criteria are documented in patient records.
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 Vaginitis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Vaginitis
Use these documentation templates to ensure complete and accurate documentation for Vaginitis. These templates include all required elements for proper coding and billing.
OB/GYN Progress Note
Specialty: Obstetrics and GynecologyRequired Elements
- Subjective symptoms
- Objective findings
- Assessment
- Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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