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ICD-10 Guide
ICD-10 CodesN76.81

N76.81

Billable

Mucositis (ulcerative) of vagina and vulva

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

Code Description

ICD-10 N76.81 is a billable code used to indicate a diagnosis of mucositis (ulcerative) of vagina and vulva.

Key Diagnostic Point:

Mucositis of the vagina and vulva, particularly in its ulcerative form, is characterized by inflammation and ulceration of the mucosal surfaces in these areas. This condition can arise from various etiologies, including infections, chemical irritants, or radiation therapy. Symptoms often include pain, burning, and discomfort during urination or sexual intercourse. The condition may be associated with other inflammatory disorders such as vulvovaginitis, which can complicate the clinical picture. Bartholin's gland disorders, such as cysts or abscesses, may also present concurrently, leading to further discomfort and necessitating careful evaluation. Diagnosis typically involves a thorough clinical examination, patient history, and possibly laboratory tests to identify underlying causes. Treatment focuses on alleviating symptoms and addressing the underlying cause, which may include topical medications, antibiotics for infections, or other therapeutic interventions. Proper documentation of the clinical findings and treatment plan is essential for accurate coding and reimbursement.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of potential underlying causes (infectious, inflammatory, chemical)
  • Overlap with other conditions like vulvovaginitis and Bartholin's gland disorders
  • Need for detailed clinical documentation to support diagnosis
  • Potential for concurrent diagnoses requiring careful coding

Audit Risk Factors

  • Insufficient documentation of symptoms and clinical findings
  • Failure to specify the underlying cause of mucositis
  • Inaccurate coding of concurrent conditions
  • Lack of follow-up documentation to support ongoing treatment

Specialty Focus

Medical Specialties

Gynecology

Documentation Requirements

Detailed patient history, examination findings, and treatment plans must be documented.

Common Clinical Scenarios

Patients presenting with vulvar pain, itching, or discharge; evaluation of Bartholin's gland cysts or abscesses.

Billing Considerations

Consideration of sexually transmitted infections (STIs) and other co-existing conditions is crucial for accurate coding.

Dermatology

Documentation Requirements

Comprehensive skin examination notes, including descriptions of lesions and any associated symptoms.

Common Clinical Scenarios

Diagnosis and management of inflammatory skin conditions affecting the vulva.

Billing Considerations

Differentiating between infectious and non-infectious causes of vulvar lesions is essential.

Coding Guidelines

Inclusion Criteria

Use N76.81 When
  • According to ICD
  • 10 coding guidelines, N76
  • 81 should be used when there is clear documentation of ulcerative mucositis of the vagina and vulva
  • It is important to ensure that the diagnosis is supported by clinical findings and that any underlying conditions are also documented

Exclusion Criteria

Do NOT use N76.81 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

88305CPT Code

Pathology examination of vulvar biopsy

Clinical Scenario

Used when a biopsy is performed to evaluate ulcerative lesions.

Documentation Requirements

Pathology report must be included in the patient's medical record.

Specialty Considerations

Gynecologists and dermatologists should ensure accurate coding based on biopsy findings.

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 ulcerative mucositis, improving the accuracy of data collection and reimbursement processes. This specificity helps in better understanding the prevalence and treatment outcomes of such conditions.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like ulcerative mucositis, improving the accuracy of data collection and reimbursement processes. This specificity helps in better understanding the prevalence and treatment outcomes of such conditions.

Reimbursement & Billing Impact

reimbursement processes. This specificity helps in better understanding the prevalence and treatment outcomes of such conditions.

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 are the common causes of ulcerative mucositis?

Common causes include infections (such as herpes simplex), chemical irritants, and radiation therapy. It is important to identify the underlying cause for appropriate treatment.

How is ulcerative mucositis diagnosed?

Diagnosis is primarily clinical, based on the presence of ulcers and associated symptoms. Laboratory tests may be performed to rule out infections.