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v1.0.0
ICD-10 Guide
ICD-10 CodesN90.61

N90.61

Billable

Childhood asymmetric labium majus enlargement

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/18/2025

Code Description

ICD-10 N90.61 is a billable code used to indicate a diagnosis of childhood asymmetric labium majus enlargement.

Key Diagnostic Point:

Childhood asymmetric labium majus enlargement refers to a condition where one side of the labium majus (the outer folds of skin surrounding the vaginal opening) is enlarged compared to the other side. This condition is typically benign and may be observed in prepubescent girls. The enlargement can be due to various factors, including hormonal influences, congenital anomalies, or localized tissue growth. Clinically, it may present as asymmetry that can be noted during routine examinations or may be reported by caregivers due to concerns about appearance or discomfort. It is essential to differentiate this condition from other potential causes of labial enlargement, such as infections or tumors, which may require further investigation. Diagnosis is primarily clinical, and treatment is usually not necessary unless the condition causes significant discomfort or psychological distress. In such cases, surgical intervention may be considered. Understanding the benign nature of this condition is crucial for healthcare providers to avoid unnecessary interventions and to reassure families.

Code Complexity Analysis

Complexity Rating: Low

Low Complexity

Complexity Factors

  • Limited differential diagnoses associated with the condition.
  • Clear clinical presentation that is typically straightforward.
  • Low likelihood of complications or comorbidities.
  • Standardized documentation requirements.

Audit Risk Factors

  • Inadequate documentation of clinical findings.
  • Failure to differentiate from inflammatory conditions.
  • Misuse of related codes leading to incorrect billing.
  • Lack of follow-up documentation if treatment is provided.

Specialty Focus

Medical Specialties

Pediatrics

Documentation Requirements

Detailed physical examination findings and parental concerns.

Common Clinical Scenarios

Routine well-child visits where labial asymmetry is noted.

Billing Considerations

Ensure that the condition is documented as benign to avoid unnecessary referrals.

Gynecology

Documentation Requirements

Comprehensive assessment of labial structure and any associated symptoms.

Common Clinical Scenarios

Evaluation of adolescent patients presenting with labial concerns.

Billing Considerations

Consideration of psychological impact on the patient and family.

Coding Guidelines

Inclusion Criteria

Use N90.61 When
  • According to ICD
  • 10 guidelines, N90
  • 61 is classified under noninflammatory disorders of the female genital tract
  • It is essential to ensure that the condition is documented as non
  • inflammatory and benign to support the use of this code

Exclusion Criteria

Do NOT use N90.61 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

58150CPT Code

Vulvectomy, partial

Clinical Scenario

Used if surgical intervention is necessary due to discomfort or psychological concerns.

Documentation Requirements

Detailed documentation of the clinical necessity for surgery.

Specialty Considerations

Gynecologists should ensure that all conservative measures have been considered before proceeding.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of conditions like childhood asymmetric labium majus enlargement, improving the accuracy of medical records and billing.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like childhood asymmetric labium majus enlargement, improving the accuracy of medical records and billing.

Reimbursement & Billing Impact

billing.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What is the primary cause of childhood asymmetric labium majus enlargement?

The primary cause is often benign tissue growth influenced by hormonal changes during childhood. It is essential to differentiate it from other pathological conditions.