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ICD-10 Guide
ICD-10 CodesB40.3

B40.3

Candidiasis of vulva and vagina

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 B40.3 is a billable code used to indicate a diagnosis of candidiasis of vulva and vagina.

Key Diagnostic Point:

Candidiasis of the vulva and vagina, commonly known as a yeast infection, is a fungal infection caused primarily by the overgrowth of Candida species, particularly Candida albicans. This condition is characterized by symptoms such as itching, burning, and abnormal vaginal discharge, which may appear thick and white, resembling cottage cheese. The infection can occur in women of all ages but is more prevalent in those who are pregnant, diabetic, or immunocompromised. Factors contributing to the development of candidiasis include antibiotic use, hormonal changes, and a weakened immune system. Diagnosis is typically made through clinical evaluation and may be confirmed with laboratory tests, including a wet mount or culture. Treatment usually involves antifungal medications, which can be administered topically or orally, depending on the severity of the infection. In immunocompromised patients, such as those with HIV/AIDS or undergoing chemotherapy, candidiasis can be more severe and recurrent, necessitating a more aggressive treatment approach and careful monitoring.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between candidiasis and other vulvovaginal infections.
  • Identifying underlying conditions that may predispose patients to recurrent infections.
  • Variability in symptoms and presentation among different patient populations.
  • Need for accurate documentation of treatment response and recurrence.

Audit Risk Factors

  • Inadequate documentation of symptoms and clinical findings.
  • Failure to document the patient's immunocompromised status.
  • Lack of follow-up documentation for recurrent infections.
  • Misclassification of candidiasis as a bacterial infection.

Specialty Focus

Medical Specialties

Obstetrics and Gynecology

Documentation Requirements

Detailed patient history, including symptoms, treatment response, and any underlying conditions.

Common Clinical Scenarios

Diagnosis and treatment of recurrent yeast infections, management of candidiasis during pregnancy.

Billing Considerations

Consideration of hormonal factors and potential interactions with other medications.

Infectious Disease

Documentation Requirements

Comprehensive documentation of immunocompromised status and any co-infections.

Common Clinical Scenarios

Management of severe or recurrent candidiasis in immunocompromised patients.

Billing Considerations

Need for detailed treatment plans and monitoring for treatment efficacy.

Coding Guidelines

Inclusion Criteria

Use B40.3 When
  • According to ICD
  • 10 coding guidelines, B40
  • 3 should be used when the diagnosis of candidiasis is confirmed and specifically affects the vulva and vagina
  • It is important to document any underlying conditions that may contribute to the infection, such as diabetes or immunocompromised status

Exclusion Criteria

Do NOT use B40.3 When
No specific exclusions found.

Related CPT Codes

87210CPT Code

Culture, fungal, any source

Clinical Scenario

Used when a fungal culture is performed to confirm candidiasis.

Documentation Requirements

Document the reason for the culture and any previous treatments.

Specialty Considerations

Obstetrics and Gynecology may require additional documentation for pregnancy-related cases.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of candidiasis, improving the ability to track and manage this condition in various patient populations, particularly those who are immunocompromised.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of candidiasis, improving the ability to track and manage this condition in various patient populations, particularly those who are immunocompromised.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of candidiasis, improving the ability to track and manage this condition in various patient populations, particularly those who are immunocompromised.

Resources

Clinical References

  • •
    CDC - Candidiasis

Coding & Billing References

  • •
    CDC - Candidiasis

Frequently Asked Questions

What are the common symptoms of candidiasis of the vulva and vagina?

Common symptoms include itching, burning, and a thick, white discharge that resembles cottage cheese. Patients may also experience discomfort during intercourse and urination.