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v1.0.0
ICD-10 Guide
ICD-10 CodesN89.4

N89.4

Billable

Leukoplakia of vagina

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

Code Description

ICD-10 N89.4 is a billable code used to indicate a diagnosis of leukoplakia of vagina.

Key Diagnostic Point:

Leukoplakia of the vagina is characterized by the presence of white patches or plaques on the vaginal mucosa, which can be indicative of various underlying conditions. This condition is often associated with chronic irritation or inflammation, and it may be a precursor to more serious conditions, including dysplasia or malignancy. The etiology of leukoplakia can vary, including factors such as chronic infections, irritants, or hormonal changes. Clinically, patients may present with symptoms such as itching, burning, or discomfort, although some may be asymptomatic. Diagnosis typically involves a thorough gynecological examination, and may require biopsy to rule out dysplastic changes or malignancy. Management strategies may include addressing the underlying cause, such as treating infections or removing irritants, and in some cases, surgical intervention may be necessary. Regular follow-up is essential to monitor for any changes that could indicate progression to more serious conditions.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between leukoplakia and other similar lesions
  • Need for biopsy results to confirm diagnosis
  • Potential association with dysplastic changes
  • Variability in presentation and symptoms

Audit Risk Factors

  • Inadequate documentation of symptoms
  • Failure to document biopsy results
  • Misclassification of leukoplakia as inflammatory
  • Lack of follow-up documentation

Specialty Focus

Medical Specialties

Gynecology

Documentation Requirements

Detailed clinical notes including symptoms, examination findings, and biopsy results.

Common Clinical Scenarios

Patients presenting with abnormal vaginal discharge, itching, or lesions.

Billing Considerations

Ensure thorough documentation of any associated conditions or treatments.

Pathology

Documentation Requirements

Histopathological reports detailing findings from biopsies.

Common Clinical Scenarios

Evaluation of biopsied tissue from patients with suspected leukoplakia.

Billing Considerations

Accurate coding based on histological findings is crucial.

Coding Guidelines

Inclusion Criteria

Use N89.4 When
  • According to ICD
  • 10 guidelines, N89
  • 4 should be used when leukoplakia is specifically diagnosed in the vagina
  • It is important to document any associated conditions or symptoms to support the diagnosis

Exclusion Criteria

Do NOT use N89.4 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

58100CPT Code

Endometrial biopsy

Clinical Scenario

When a biopsy is performed to evaluate abnormal findings associated with leukoplakia.

Documentation Requirements

Document indication for biopsy and findings.

Specialty Considerations

Gynecologists should ensure clear linkage between diagnosis and procedure.

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 leukoplakia, improving the accuracy of diagnoses and treatment tracking.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like leukoplakia, improving the accuracy of diagnoses and treatment tracking.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of conditions like leukoplakia, improving the accuracy of diagnoses and treatment tracking.

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 leukoplakia of the vagina?

Leukoplakia can be caused by chronic irritation, infections, or hormonal changes. It is important to evaluate the underlying cause to determine appropriate management.