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ICD-10 Guide
ICD-10 CodesN94.12

N94.12

Billable

Deep dyspareunia

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

Code Description

ICD-10 N94.12 is a billable code used to indicate a diagnosis of deep dyspareunia.

Key Diagnostic Point:

Deep dyspareunia refers to pain experienced during sexual intercourse that is felt deep within the pelvis. This condition can significantly impact a woman's quality of life, emotional well-being, and sexual relationships. It is often associated with various underlying medical conditions, including endometriosis, pelvic inflammatory disease, uterine fibroids, and ovarian cysts. Hormonal changes, particularly during menstruation or menopause, can exacerbate symptoms. Additionally, psychological factors such as anxiety, depression, or a history of sexual trauma may contribute to the severity of dyspareunia. Accurate diagnosis typically involves a thorough medical history, physical examination, and possibly imaging studies to identify any anatomical or pathological causes. Treatment options may include medication for pain relief, hormonal therapy, pelvic floor physical therapy, or counseling to address psychological factors. Understanding the multifaceted nature of deep dyspareunia is crucial for effective management and improving patient outcomes.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of potential underlying causes requiring thorough documentation.
  • Need for differentiation from other types of dyspareunia.
  • Potential overlap with psychological conditions that may complicate coding.
  • Variability in patient presentation and symptom severity.

Audit Risk Factors

  • Inadequate documentation of the underlying causes.
  • Failure to differentiate between deep and superficial dyspareunia.
  • Lack of supporting evidence for associated conditions.
  • Inconsistent coding practices across specialties.

Specialty Focus

Medical Specialties

Gynecology

Documentation Requirements

Detailed patient history, physical examination findings, and any imaging or lab results.

Common Clinical Scenarios

Patients presenting with pelvic pain, history of endometriosis, or after pelvic surgery.

Billing Considerations

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

Psychiatry

Documentation Requirements

Assessment of psychological factors, including mental health history and any trauma-related issues.

Common Clinical Scenarios

Patients with a history of sexual trauma or anxiety disorders presenting with dyspareunia.

Billing Considerations

Documenting the psychological impact of dyspareunia on the patient's mental health is crucial.

Coding Guidelines

Inclusion Criteria

Use N94.12 When
  • According to ICD
  • 10 guidelines, N94
  • 12 should be used when deep dyspareunia is specifically documented
  • It is important to ensure that the diagnosis is supported by clinical findings and that any associated conditions are also coded appropriately

Exclusion Criteria

Do NOT use N94.12 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

58150CPT Code

Total abdominal hysterectomy

Clinical Scenario

Used when surgical intervention is necessary for conditions causing deep dyspareunia.

Documentation Requirements

Operative report detailing the procedure and indication for surgery.

Specialty Considerations

Gynecologists should ensure that the diagnosis is clearly linked to the surgical 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 deep dyspareunia, improving the accuracy of diagnoses and treatment plans. This specificity aids in better understanding and management of the condition.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like deep dyspareunia, improving the accuracy of diagnoses and treatment plans. This specificity aids in better understanding and management of the condition.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of conditions like deep dyspareunia, improving the accuracy of diagnoses and treatment plans. This specificity aids in better understanding and management of the condition.

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 deep dyspareunia?

Deep dyspareunia is a type of pain experienced during sexual intercourse that is felt deep within the pelvis, often linked to various medical conditions.

How is deep dyspareunia diagnosed?

Diagnosis typically involves a thorough medical history, physical examination, and possibly imaging studies to identify underlying causes.

What are common treatments for deep dyspareunia?

Treatment may include pain relief medications, hormonal therapy, pelvic floor physical therapy, and counseling for psychological factors.