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ICD-10 Guide
ICD-10 CodesN94.10

N94.10

Billable

Unspecified dyspareunia

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

Code Description

ICD-10 N94.10 is a billable code used to indicate a diagnosis of unspecified dyspareunia.

Key Diagnostic Point:

Unspecified dyspareunia refers to recurrent or persistent pain during sexual intercourse that cannot be attributed to a specific medical condition. This condition can significantly impact a woman's quality of life, emotional well-being, and intimate relationships. Dyspareunia can arise from various factors, including hormonal changes associated with menstrual and menopausal disorders, psychological issues, or anatomical abnormalities. In the context of menstrual disorders, conditions such as endometriosis or pelvic inflammatory disease may contribute to dyspareunia. Menopausal changes, including decreased estrogen levels, can lead to vaginal atrophy, resulting in discomfort during intercourse. Additionally, women experiencing infertility or undergoing artificial fertilization may encounter dyspareunia due to hormonal treatments or psychological stress. Accurate diagnosis and management are crucial, as dyspareunia can be a symptom of underlying reproductive health issues that require attention. Treatment options may include hormonal therapy, counseling, or physical therapy, depending on the underlying cause.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in underlying causes of dyspareunia
  • Need for comprehensive patient history and examination
  • Potential overlap with other gynecological conditions
  • Documentation of psychological factors

Audit Risk Factors

  • Insufficient documentation of symptoms
  • Failure to specify underlying causes
  • Inconsistent coding with treatment provided
  • Lack of patient history related to reproductive health

Specialty Focus

Medical Specialties

Gynecology

Documentation Requirements

Detailed patient history, including menstrual and sexual history, physical examination findings, and any psychological assessments.

Common Clinical Scenarios

Patients presenting with pelvic pain, discomfort during intercourse, or complaints related to hormonal changes.

Billing Considerations

Ensure that all potential causes are explored and documented to support the diagnosis of unspecified dyspareunia.

Psychiatry

Documentation Requirements

Assessment of psychological factors contributing to dyspareunia, including mental health history and any relevant therapy notes.

Common Clinical Scenarios

Patients with a history of anxiety or depression presenting with sexual dysfunction.

Billing Considerations

Collaboration with gynecologists may be necessary to address both physical and psychological aspects of dyspareunia.

Coding Guidelines

Inclusion Criteria

Use N94.10 When
  • According to ICD
  • 10 guidelines, N94
  • 10 should be used when dyspareunia is documented without a specified cause
  • Coders should ensure that all relevant clinical information is captured to support the diagnosis

Exclusion Criteria

Do NOT use N94.10 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

99213CPT Code

Established patient office visit, Level 3

Clinical Scenario

Used for follow-up visits regarding dyspareunia management.

Documentation Requirements

Document patient history, examination findings, and treatment plan.

Specialty Considerations

Ensure that the visit is clearly linked to the management of dyspareunia.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of dyspareunia, enabling better tracking of the condition and its underlying causes. This specificity aids in research and treatment planning.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of dyspareunia, enabling better tracking of the condition and its underlying causes. This specificity aids in research and treatment planning.

Reimbursement & Billing Impact

reimbursement.

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 unspecified dyspareunia?

Unspecified dyspareunia can arise from various factors, including hormonal changes, psychological issues, and anatomical abnormalities. A thorough evaluation is necessary to identify potential causes.