ICD-10 Code A56.02 | Chlamydial vulvovaginitis Symptoms, Diagnosis, Billing

Chlamydial vulvovaginitis is an infection caused by the bacterium Chlamydia trachomatis, primarily affecting the vulva and vagina. It is clinically significant due to its potential to cause severe reproductive health issues, including pelvic inflammatory disease and infertility. Accurate coding with ICD-10 Code A56.02 is essential for proper diagnosis, documentation, medical billing, and public health reporting.

What is ICD-10 Code A56.02 for Chlamydial vulvovaginitis?

ICD-10 Code A56.02 specifically represents chlamydial vulvovaginitis, a sexually transmitted infection characterized by inflammation of the vulva and vagina due to Chlamydia trachomatis. This code should be used in clinical documentation and billing when diagnosing patients with this condition, ensuring accurate representation of the underlying disease and facilitating appropriate treatment.

ICD-10 Code A56.02 – Clinical Definition and Explanation of Chlamydial vulvovaginitis

Chlamydial vulvovaginitis is primarily caused by the bacterium Chlamydia trachomatis, which can lead to significant reproductive health complications if left untreated. The condition often requires medical attention due to its potential to progress to more severe infections. Early diagnosis and treatment are crucial for preventing long-term health issues.

Key Clinical Features:

• Vulvar itching and irritation
• Abnormal vaginal discharge
• Dysuria (painful urination)
• Pelvic pain or discomfort

ICD-10 Code A56.02 for Chlamydial vulvovaginitis – SOAP Notes & Clinical Use

ICD-10 Code A56.02 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans. This code is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition and guiding appropriate management strategies.

What Does ICD-10 Code A56.02 for Chlamydial vulvovaginitis Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A56.02 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of chlamydial vulvovaginitis. This coding ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code A56.02 – Chlamydial vulvovaginitis

Chlamydial vulvovaginitis requires prompt treatment to prevent complications. Antibiotic therapy is the primary treatment approach, and hospitalization may be necessary in severe cases.

Antibiotic Therapy:

• Azithromycin 1 g orally in a single dose
• Doxycycline 100 mg orally twice daily for 7 days
• Alternative: Levofloxacin 500 mg orally once daily for 7 days

Supportive Care:

• Pain management with NSAIDs
• Education on safe sexual practices
• Follow-up testing for reinfection

Infection Control:

• Encourage partner notification and treatment
• Advise on safe sex practices to prevent transmission
• Monitor for outbreaks in community settings

How to Document Symptoms of Chlamydial vulvovaginitis (ICD-10 A56.02) in SOAP Notes

Subjective:

• Patient reports vulvar itching and irritation.
• Complains of abnormal vaginal discharge.
• Experiences dysuria and pelvic discomfort.
• History of unprotected sexual intercourse.

Objective:

• Vulvar erythema and edema observed on examination.
• Purulent vaginal discharge noted.
• Positive urine test for Chlamydia trachomatis.
• No fever or systemic signs of infection.

Secure, compliant, and built for trust

HIPAA-compliant and designed with privacy in mind, your patient’s data is protected. Focus on care while we safeguard your information.

Learn more

SOAP Note Guidelines for Diagnosing Chlamydial vulvovaginitis (ICD-10 Code A56.02)

Assessment:

• Diagnosis: Chlamydial vulvovaginitis, mild severity.
• ICD-10 Code: A56.02.
• Contributing factors: Recent unprotected sexual activity.
• No signs of systemic infection.

Plan:

• Initiate treatment with Azithromycin 1 g orally.
• Educate patient on safe sexual practices.
• Schedule follow-up appointment in 1 week.
• Consider retesting for Chlamydia after treatment.

Treatment & Plan Section for ICD-10 Code A56.02 – Chlamydial vulvovaginitis

• First-line treatment with Azithromycin or Doxycycline.
• Patient education on the importance of completing the antibiotic course.
• Monitoring for symptom resolution and potential reinfection.
• Follow-up testing recommended 3 months post-treatment.

Using ICD-10 Code A56.02 for Chlamydial vulvovaginitis in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings.
• Use the code in appropriate clinical settings, including outpatient and emergency care.
• Align treatment plans with clinical guidelines for justified billing.
• Document patient education and follow-up plans to support claims.

Related ICD-10 Codes Often Used with Chlamydial vulvovaginitis

• A56.01 – Chlamydial cervicitis
• A56.03 – Chlamydial pelvic inflammatory disease
• A56.9 – Chlamydial infection, unspecified
• N70.9 – Inflammatory disease of the female pelvic organs, unspecified

ICD-10 Code A56.02 in Medical Billing and Insurance for Chlamydial vulvovaginitis

ICD-10 Code A56.02 is critical in medical billing, particularly in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant patient history and clinical findings to support the claim.
• Use the code in outpatient and inpatient settings as appropriate.
• Ensure that treatment plans are clearly outlined in the medical record.

Common CPT Pairings: