Ob-Gyn Coding Alert

Question: Code N76 (Other inflammation of vagina and vulva) shows a message in red underneath this code stating: “Use additional code (B95-B97), to identify infectious agent.” I was told by one of our MDs that these specific bacterial and viral tests are almost never tested for vaginitis. They may check and affirm, which will tell in general if yeast or bacteria are present, but they don’t know which type. So my question is how are we supposed to know this info, and is it a requirement to code it each time?

Louisiana Subscriber

Answer: The ICD-10 instruction is to report the agent that is causing the infection and to code correctly that is what should be done. However, many times, the wet mount/KOH will indicate the presence of bacterial vaginosis and clinically no further testing is required.  In fact, BV is caused when the normal balance of good and bad bacterial in the vaginal canal is disrupted. The culprit is usually Gardnerella vaginalis, but clinical texts indicate that additional testing is not required if clue cells are present and the whiff test is positive.

So what to do?  The alphabetic index indicates you should report N76.0 (Acute vaginitis) for this condition which leads us back to the dilemma. Experts suggest that B96.89 (Other specified bacterial agents as the cause of diseases classified elsewhere) may fit the bill here. 

If the wet mount/KOH instead shows yeast or trichomonas, a diagnosis of vaginitis would not be reported – instead you would go with A59.01 (Trichomonal vulvovaginitis) or B37.3 (Candidiasis of vulva and vagina).  And of course, if the wet mount/KOH is normal, a code for the vaginal discharge   (N89.8, Other specified noninflammatory disorders of vagina), not vaginitis would be more correct.