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Wiki postmenopausal vaginits

Emmy1260

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Wausau, WI
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Physician documents "vulvitis in post menopausal female" Would you code
616.10 vaginitis with 49.81 Asymptomatic postmenopausal status -or- 627.3 postmenopausal atrophic vaginitis? There is not any notation of vaginal atrophy, not does the physician specifically state that the one is cause of the other.

Also, patient has history of breast cancer with past tamoxifen use and is currently using estrogen replacement. How would you address the estrogen use both past and present?
 
Vaginitis

If the physician is treating her for vulvitis, I would only code 616.10.
And I am getting personal history of estrogen therapy V87.43 for both past and present. Hope that helps :)
 
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