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Posted By Lillian on 07-14-2016, 09:50:32 in Ob-Gyn
N76-Other inflammation of vagina and vulva show a message in red underneath this code stating: Use additional code (B95-B97), to identify infectious agent.
I was told by one of our md's that these specific bacterial and viral tests are almost never tested for vaginitis. They may check an 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?
Comments (7)
Posted By Melanie Witt on 07-27-2016, 16:12:22
If a culture was ordered, I would wait and bill until you get the results, just as you would for an operative report before coding for the surgery. If you must bill on the same date of service and you don't have a positive wet mount then code it as vaginal discharge (N89.8, Other specified noninflammatory disorders of vagina), not vaginitis.
Posted By Lillian on 07-21-2016, 16:50:54
What if they don't know at the time they're coding the chart which organism is causing it hence why ordering the culture? Should they code it as Vag Discharge then and Not vaginitis or should they wait for culture results in order to code it?
Posted By Lillian on 07-21-2016, 15:57:00
But just because a wet mount is negative doesn't mean that an organism will not be detected on culture or suspected by exam. So what should they code then?
Posted By Melanie Witt on 07-15-2016, 17:36:53
Oh, and if the wet mount tests are normal you should not be coding vaginitis at all.
Posted By Melanie Witt on 07-15-2016, 17:34:33
The physician would have to order another test to find out the exact organism which if yeast is present they would not have to do and should be reporting the B37.3 (Candidiasis of vulva and vagina) instead. Remember you are coding vaginitis which is supposed to be caused by an organism and all ICD10 is saying, what is that organism?
Posted By Lillian on 07-14-2016, 18:23:34
What is the proper protocol for them into obtaining this information in order to document it?
Posted By Melanie Witt on 07-14-2016, 18:14:00
What ICD10 tells you is the rule you must follow. Providers do not always comply and if you were audited you might get a finding. Specific complete coding should always be the goal, but sometimes clinical practice does not match the rules. The note should probably read, if known, but it does not.
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