Find comprehensive information on Vaginal Candidiasis, including clinical documentation tips, ICD-10 code B37.3, and SNOMED CT concepts. Learn about diagnosing yeast infection, vulvovaginal candidiasis symptoms, and treatment options. This resource offers guidance for healthcare professionals on accurate medical coding and best practices for documenting Candida albicans infections in patient charts. Explore relevant differential diagnoses and understand the clinical presentation of vaginal candidiasis for improved patient care.
Also known as
Candidal vulvovaginitis
Vaginal yeast infection caused by Candida species.
Candidiasis of other urogenital sites
Candida infection of urinary tract or other genitals.
Inflammatory diseases of vagina
Includes various vaginal inflammations, sometimes related to candidiasis.
Mycoses
Encompasses broader fungal infections, including candidiasis.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the vaginal candidiasis uncomplicated?
When to use each related code
| Description |
|---|
| Vaginal yeast infection |
| Bacterial vaginosis |
| Trichomoniasis |
Coding B37.3 (candidiasis NOS) without documenting specific site like vagina lacks specificity, impacting reimbursement and data accuracy. Use B37.4 for vaginal candidiasis.
Coding candidiasis based on symptoms alone without lab confirmation or definitive clinical findings risks overcoding and inaccurate quality reporting. Document diagnostic basis.
Failing to distinguish uncomplicated (B37.4) from complicated (B37.8) candidiasis impacts severity coding, affecting resource utilization tracking and potential HCC coding for risk adjustment.
Subjective: Patient presents with complaints consistent with vulvovaginal candidiasis (VVC), also known as a yeast infection. Symptoms include vulvar pruritus, vaginal itching, and a thick, white, cottage cheese-like vaginal discharge. Patient reports burning sensation with urination (dysuria) and discomfort during intercourse (dyspareunia). Onset of symptoms reported approximately three days ago. Patient denies fever, chills, abdominal pain, or unusual vaginal odor. Past medical history includes recurrent yeast infections, estimated at three episodes in the past year. No known drug allergies. Current medications include an oral contraceptive. Objective: Physical examination reveals erythematous vulva with excoriations noted. Vaginal mucosa appears inflamed with adherent white plaques. Speculum examination confirms thick, white discharge. Vaginal pH is 4.0. Wet mount microscopy reveals budding yeast and pseudohyphae, confirming the diagnosis of vaginal candidiasis. Assessment: Vaginal Candidiasis (ICD-10: B37.3). Differential diagnoses considered included bacterial vaginosis and trichomoniasis, but were ruled out based on clinical presentation and microscopic findings. Recurrent vulvovaginal candidiasis is suspected given the patient's history. Plan: Patient educated on the diagnosis of vaginal candidiasis, risk factors, and preventative measures. Treatment prescribed with Fluconazole 150mg oral tablet, single dose (Rx: Fluconazole 150mg PO x 1). Patient advised on proper medication administration and potential side effects. Recommended avoidance of irritants such as scented soaps and tight-fitting clothing. Discussed the importance of maintaining proper hygiene and the use of cotton underwear. Follow-up recommended if symptoms persist or worsen after treatment. Patient counseling included information on over-the-counter antifungal treatments for future episodes, emphasizing the importance of confirming the diagnosis with a healthcare professional before self-treating. Patient encouraged to schedule a follow-up appointment to discuss long-term management strategies for recurrent yeast infections, including prophylactic antifungal medications if deemed appropriate.