ICD-10 Coding for Bacterial Vaginosis(N89.1, N76.0)
Complete ICD-10-CM coding and documentation guide for Bacterial Vaginosis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Bacterial Vaginosis
N89-N89.9Primary Range
Other noninflammatory disorders of vagina
This range includes codes for noninflammatory vaginal conditions, with N89.1 specifically for bacterial vaginosis.
Inflammatory diseases of vagina, vulva
This range includes codes for inflammatory conditions of the vagina, such as acute vaginitis, which may be used if inflammation is present without BV confirmation.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N89.1 | Vaginal dysbacteriosis | Use when bacterial vaginosis is confirmed through clinical criteria or molecular testing. |
|
| N76.0 | Acute vaginitis | Use when acute inflammation is documented without confirmation of BV. |
|
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 Bacterial Vaginosis
Primary ICD-10-CM Codes for bacterial vaginosis
Decision Criteria
clinical Criteria
- Presence of ≥3 Amsel criteria or positive NAAT
documentation Criteria
- Detailed documentation of clinical findings
Clinical Validation Requirements
- Presence of ≥3 Amsel criteria
- NAAT positive for Gardnerella vaginalis
Code-Specific Risks
- Misclassification if criteria are not documented
- Potential audit if used without proper validation
Coding Notes
- Ensure documentation of Amsel criteria or molecular test results for accurate coding.
N76.0 - Acute vaginitis
Use when acute inflammation is documented without confirmation of BV.
Applicable To
- Acute inflammatory conditions of the vagina
Excludes
- Bacterial vaginosis (N89.1)
Clinical Validation Requirements
- Microscopy showing neutrophils >10/hpf
Coding Notes
Ensure documentation specifies acute inflammation.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Screening for sexually transmitted infections
Z11.3Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Bacterial Vaginosis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N89.1.
Impact
Clinical: May lead to incorrect treatment., Regulatory: Non-compliance with coding standards., Financial: Potential for denied claims.
Mitigation Strategy
Ensure detailed documentation of clinical findings., Use specific terminology related to BV.
Impact
Reimbursement: Incorrect coding may lead to reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Impacts accuracy of clinical data.
Mitigation Strategy
Query provider to confirm if BV is present or if it's nonspecific vaginitis.
Impact
Using N76.0 instead of N89.1 for confirmed BV.
Mitigation Strategy
Ensure documentation supports the use of N89.1 with clinical criteria.
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 Bacterial Vaginosis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Bacterial Vaginosis
Use these documentation templates to ensure complete and accurate documentation for Bacterial Vaginosis. These templates include all required elements for proper coding and billing.
OB/GYN Clinic Visit
Specialty: Obstetrics and GynecologyRequired Elements
- Patient symptoms
- Clinical findings
- Lab results
- Diagnosis
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Bacterial Vaginosis? Ask your questions below.