ICD-10 Coding for Vulvovaginal Atrophy(N95.2, N76.89)
Complete ICD-10-CM coding and documentation guide for Vulvovaginal Atrophy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Vulvovaginal Atrophy
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N95.2 | Postmenopausal atrophic vaginitis | Use when the patient is postmenopausal and presents with symptoms of vaginal atrophy. |
|
| N76.89 | Other specified inflammation of vagina and vulva | Use for atrophic vaginitis in non-postmenopausal patients. |
|
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 vulvovaginal atrophy
Essential facts and insights about Vulvovaginal Atrophy
Primary ICD-10-CM Codes for vulvovaginal atrophy
Decision Criteria
clinical Criteria
- Patient is postmenopausal with symptoms of vaginal atrophy.
documentation Criteria
- Documented vaginal pH and maturation index.
Applicable To
- Postmenopausal vaginal atrophy
Excludes
- Non-postmenopausal atrophic vaginitis (N76.89)
Clinical Validation Requirements
- Vaginal pH ≥4.6
- Vaginal Maturation Index <15
- Symptoms of dryness and dyspareunia
Code-Specific Risks
- Incorrectly coding non-postmenopausal cases as N95.2
Coding Notes
- Ensure menopausal status is documented to support the use of N95.2.
N76.89 - Other specified inflammation of vagina and vulva
Use for atrophic vaginitis in non-postmenopausal patients.
Applicable To
- Non-postmenopausal atrophic vaginitis
Excludes
- Postmenopausal atrophic vaginitis (N95.2)
Clinical Validation Requirements
- Symptoms of vaginal atrophy without postmenopausal status
Coding Notes
Ensure the etiology of atrophy is documented if not postmenopausal.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Vulvovaginal Atrophy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N95.2.
Impact
Clinical: Misdiagnosis risk., Regulatory: Non-compliance with coding standards., Financial: Potential reimbursement issues.
Mitigation Strategy
Always verify and document menopausal status., Use templates that prompt for this information.
Impact
Reimbursement: May lead to incorrect reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data.
Mitigation Strategy
Verify menopausal status before coding.
Impact
Failure to document menopausal status can lead to audit issues.
Mitigation Strategy
Implement mandatory fields in EHR for menopausal status.
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 Vulvovaginal Atrophy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Vulvovaginal Atrophy
Use these documentation templates to ensure complete and accurate documentation for Vulvovaginal Atrophy. These templates include all required elements for proper coding and billing.
Postmenopausal VVA Diagnosis
Specialty: GynecologyRequired Elements
- Chief complaint
- Menopausal status
- Vaginal pH
- Vaginal Maturation Index
- Symptoms
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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