Understand abnormal vaginal discharge (leukorrhea) diagnosis, documentation, and medical coding. Find information on causes, symptoms, and treatment of vaginal discharge. Learn about relevant ICD-10 codes, clinical terminology, and healthcare best practices for accurate documentation and coding related to leukorrhea and abnormal vaginal discharge. This resource supports clinicians, coders, and healthcare professionals.
Also known as
Other inflammatory diseases of vagina
Covers various inflammatory vaginal conditions, including abnormal discharge.
Gonococcal infection
Gonorrhea can cause vaginal discharge as a symptom.
Anogenital herpesviral infection
Herpes infections can present with vaginal discharge.
Candidiasis
Vaginal candidiasis (yeast infection) often causes discharge.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the discharge specified as physiological?
Yes
Consider N98.8 Other specified abnormal findings of the genital organs
No
Is there infection/inflammation?
When to use each related code
| Description |
|---|
| Unusual vaginal discharge (color, odor, amount) |
| White/gray discharge, fishy odor, often with itching |
| Thick, white, cottage cheese-like discharge, itching |
Coding A99.8 requires specificity. Documenting discharge characteristics (color, odor, amount) supports accurate coding and reduces audit risk. Consider N76.0-N76.8
Vaginal discharge can indicate infection (e.g., candidiasis, vaginosis). Distinguishing nonspecific discharge (N76.-) from infection is crucial for accurate coding and reimbursement.
If discharge follows a procedure, code the procedure and its related complications, not just the symptom. Linking A99.8 to the procedure ensures coding accuracy.
Q: What are the most common differential diagnoses for abnormal vaginal discharge in adult women, considering factors like color, odor, and consistency?
A: Differential diagnoses for abnormal vaginal discharge require careful consideration of patient history, symptoms, and examination findings. A thick, white, cottage cheese-like discharge often points towards vulvovaginal candidiasis (yeast infection). A thin, gray or off-white discharge with a fishy odor, particularly after intercourse, suggests bacterial vaginosis (BV). A yellow or green, frothy discharge may indicate trichomoniasis. Other possibilities include cervicitis, foreign body, or even physiological discharge, which varies throughout the menstrual cycle. Accurate diagnosis requires microscopic examination of vaginal secretions (wet mount) and potentially pH testing or cultures. Explore how point-of-care testing can expedite diagnosis and treatment in your practice.
Q: How do I differentiate between bacterial vaginosis and a yeast infection based on clinical presentation and diagnostic testing in a primary care setting?
A: Differentiating between bacterial vaginosis (BV) and vulvovaginal candidiasis (yeast infection) relies on several key features. BV typically presents with a thin, gray/off-white, homogenous discharge with a characteristic fishy odor, particularly after intercourse. Yeast infections present with a thick, white, cottage cheese-like discharge, often accompanied by vulvar itching, burning, and dysuria. A vaginal pH > 4.5 suggests BV, while a normal vaginal pH (3.8-4.5) is more common in yeast infections. Microscopic examination (wet mount) can confirm the diagnosis. For BV, look for clue cells (epithelial cells covered with bacteria). For yeast infections, look for budding yeast or pseudohyphae. Consider implementing a standardized diagnostic and treatment algorithm for vaginal discharge to improve patient outcomes. Learn more about the Amsel criteria for BV diagnosis.
Patient presents with complaints of abnormal vaginal discharge, also described as leukorrhea. The patient reports [onset, duration, and character of discharge; e.g., "a thick, white discharge for the past two weeks," "a yellow, foul-smelling discharge for three days," "a watery, gray discharge with a fishy odor for one week"]. Associated symptoms include [list any accompanying symptoms such as itching, burning, pelvic pain, dyspareunia, postcoital bleeding, or fever]. Patient's menstrual history is [describe regularity, duration, and flow of menses; e.g., "regular, 28-day cycle with a 5-day flow," "irregular menses," "last menstrual period (LMP) was two weeks ago"]. Sexual history includes [describe sexual activity, number of partners, and use of contraception; e.g., "sexually active with one partner, using condoms inconsistently," "not sexually active"]. On physical examination, the vulva and vagina appear [describe appearance, e.g., "erythematous and edematous," "normal," "with excoriations"]. Speculum examination reveals [describe discharge characteristics, e.g., "a thick, white, adherent discharge," "a thin, gray discharge with a fishy odor," "a yellow, purulent discharge"]. Cervix is [describe appearance, e.g., "friable," "normal," "with erythema"]. Bimanual examination reveals [describe uterine and adnexal findings, e.g., "normal-sized, non-tender uterus and adnexa," "uterine tenderness," "adnexal masses"]. Differential diagnoses include bacterial vaginosis, vulvovaginal candidiasis, trichomoniasis, cervicitis, and other sexually transmitted infections (STIs). A wet mount microscopy, vaginal pH, and Whiff test were performed to aid in diagnosis. [Describe results of diagnostic tests, e.g., "Wet mount revealed clue cells and a pH of 5.0, suggestive of bacterial vaginosis," "Whiff test was positive," "KOH prep revealed pseudohyphae and budding yeast, consistent with candidiasis"]. Based on clinical presentation and diagnostic findings, the diagnosis of [specific diagnosis, e.g., "bacterial vaginosis," "vulvovaginal candidiasis," "trichomoniasis"] is made. The patient was prescribed [medication and dosage; e.g., "Metronidazole 500 mg orally twice daily for 7 days," "Fluconazole 150 mg orally as a single dose"]. Patient education was provided regarding [relevant topics; e.g., "medication administration, hygiene practices, safe sex practices, and follow-up care"]. Follow-up appointment scheduled in [timeframe; e.g., "one week," "two weeks"].