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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:

Atrophic VaginitisVaginal Atrophy

Related ICD-10 Code Ranges

Complete code families applicable to Vulvovaginal Atrophy

N95-N99Primary Range

Other Disorders of the Genitourinary System

This range includes codes for postmenopausal and other specified inflammatory disorders of the vagina and vulva.

Other Inflammation of Vagina and Vulva

This range includes codes for non-postmenopausal atrophic vaginitis.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
N95.2Postmenopausal atrophic vaginitisUse when the patient is postmenopausal and presents with symptoms of vaginal atrophy.
  • Vaginal pH ≥4.6
  • Vaginal Maturation Index <15
  • Symptoms of dryness and dyspareunia
N76.89Other specified inflammation of vagina and vulvaUse for atrophic vaginitis in non-postmenopausal patients.
  • Symptoms of vaginal atrophy without postmenopausal status

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

The ICD-10 code for postmenopausal vulvovaginal atrophy is N95.2. For non-postmenopausal cases, use N76.89.

Primary ICD-10-CM Codes for vulvovaginal atrophy

Postmenopausal atrophic vaginitis
Billable Code

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.

Ancillary Codes

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

Pelvic and perineal pain

R10.2
Use when documenting associated symptoms like dyspareunia.

Frequency of urination

R35.1
Use when documenting urinary symptoms associated with VVA.

Differential Codes

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

Other specified inflammation of vagina and vulva

N76.89
Use for non-postmenopausal atrophic vaginitis.

Postmenopausal atrophic vaginitis

N95.2
Use for postmenopausal atrophic vaginitis.

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: Gynecology

Required Elements

  • Chief complaint
  • Menopausal status
  • Vaginal pH
  • Vaginal Maturation Index
  • Symptoms

Example Documentation

Postmenopausal female presents with dyspareunia and dryness. Vaginal pH 5.2, VMI shows 80% parabasal cells.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Vaginal atrophy noted.
Good Documentation Example
Postmenopausal female with dyspareunia, vaginal pH 5.2, VMI 80% parabasal cells.
Explanation
The good example provides specific clinical details and menopausal status.

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