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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:

Vaginal InfectionVaginal Inflammation

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

CodeDescriptionWhen to UseKey Documentation
N76.0Acute vaginitisUse for acute bacterial vaginosis when clinical criteria such as Amsel criteria are met.
  • Fishy odor
  • Clue cells on wet mount
  • pH >4.5
  • + 1 more
N76.1Subacute and chronic vaginitisUse for chronic or subacute presentations of vaginitis.
  • Symptoms persisting for more than 6 weeks
  • Recurrent episodes
A59.01Trichomonal vulvovaginitisUse when trichomoniasis is confirmed via laboratory testing.
  • Frothy yellow discharge
  • Motile trichomonads on wet mount
  • PCR positive for T. vaginalis
B37.3Candidal vulvovaginitisUse when candidal infection is confirmed via laboratory testing.
  • Cottage-cheese discharge
  • Pseudohyphae on KOH prep
  • PCR positive for Candida species

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

The ICD-10 code for bacterial vaginosis is N76.0, used when clinical criteria such as Amsel criteria are met.

Primary ICD-10-CM Codes for vaginitis

Acute vaginitis
Billable Code

Decision Criteria

clinical Criteria

  • Presence of Amsel criteria

documentation Criteria

  • Detailed description of discharge and test results

Applicable To

  • Bacterial vaginosis

Excludes

  • Trichomonal vaginitis (A59.01)
  • Candidal vaginitis (B37.3)

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.

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Other specified bacterial agents

B96.89
Use when a specific bacterial agent is identified in conjunction with N76.0.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Trichomonal vulvovaginitis

A59.01
Presence of motile trichomonads on wet mount or PCR positive for T. vaginalis.

Candidal vulvovaginitis

B37.3
Presence of pseudohyphae on KOH prep or PCR positive for Candida species.

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 Gynecology

Required Elements

  • Subjective symptoms
  • Objective findings
  • Assessment
  • Plan

Example Documentation

**Subjective**: CC: “Itching and fishy odor x 3 days.” Denies new partners. **Objective**: Discharge: Thin, gray, adherent. pH: 4.7. Whiff test: Positive. Microscopy: Clue cells (30%), no trichomonads. **Assessment**: Acute bacterial vaginosis (N76.0). **Plan**: Metronidazole 500mg BID x7d.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Patient has vaginitis. Prescribe metronidazole.
Good Documentation Example
Acute onset of malodorous gray discharge. pH 5.0, clue cells (20% of epithelial cells), positive amine odor. N76.0 coded.
Explanation
The good example provides specific clinical findings supporting the diagnosis and coding.

Need help with ICD-10 coding for Vaginitis? Ask your questions below.

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