ICD-10 Code A59.01 | Trichomonal vulvovaginitis Symptoms, Diagnosis, Billing

Trichomonal vulvovaginitis is a sexually transmitted infection caused by the protozoan parasite Trichomonas vaginalis. It is clinically significant due to its association with increased risk of HIV transmission and other sexually transmitted infections. Accurate coding with ICD-10 Code A59.01 facilitates proper diagnosis, documentation, medical billing, and public health reporting, ensuring effective management and treatment of affected patients.

What is ICD-10 Code A59.01 for Trichomonal vulvovaginitis?

ICD-10 Code A59.01 specifically denotes Trichomonal vulvovaginitis, an infection characterized by inflammation of the vulva and vagina due to Trichomonas vaginalis. This code should be used in clinical documentation and billing when diagnosing patients presenting with symptoms such as vaginal discharge, itching, and discomfort, ensuring accurate representation of the condition for treatment and reimbursement purposes.

ICD-10 Code A59.01 – Clinical Definition and Explanation of Trichomonal vulvovaginitis

Trichomonal vulvovaginitis is primarily caused by the protozoan parasite Trichomonas vaginalis, which is transmitted through sexual contact. The condition can lead to significant discomfort and complications if left untreated, necessitating prompt medical attention.

Key Clinical Features:

• Frothy, yellow-green vaginal discharge with a strong odor.
• Vulvar itching and irritation.
• Dyspareunia (painful intercourse).
• Inflammation and erythema of the vaginal mucosa.

ICD-10 Code A59.01 for Trichomonal vulvovaginitis – SOAP Notes & Clinical Use

ICD-10 Code A59.01 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans. It is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition and facilitating appropriate management.

What Does ICD-10 Code A59.01 for Trichomonal vulvovaginitis Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A59.01 connects subjective patient-reported symptoms with objective clinical findings, leading to a formal diagnosis. This code is essential for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A59.01 – Trichomonal vulvovaginitis

Trichomonal vulvovaginitis requires prompt treatment to alleviate symptoms and prevent complications. Antibiotic therapy is the primary treatment approach.

Antibiotic Therapy:

• Metronidazole 500 mg orally twice daily for 7 days.
• Tinidazole 2 g orally as a single dose.
• Alternative: Metronidazole 2 g orally as a single dose.

Supportive Care:

• Educate patients on safe sexual practices.
• Encourage hydration and symptom management.
• Advise on avoiding irritants such as soaps and douches.

Infection Control:

• Recommend abstaining from sexual intercourse until treatment is completed.
• Inform sexual partners to seek evaluation and treatment.
• Implement routine screening in high-risk populations.

How to Document Symptoms of Trichomonal vulvovaginitis (ICD-10 A59.01) in SOAP Notes

Subjective:

• Patient reports vaginal itching and burning.
• Complains of a foul-smelling, frothy discharge.
• History of recent unprotected sexual intercourse.
• Denies fever or abdominal pain.

Objective:

• Vaginal examination reveals erythema and discharge.
• pH of vaginal secretions is elevated (>4.5).
• Microscopic examination shows motile trichomonads.
• No signs of cervicitis or pelvic inflammatory disease.

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SOAP Note Guidelines for Diagnosing Trichomonal vulvovaginitis (ICD-10 Code A59.01)

Assessment:

• Diagnosis: Trichomonal vulvovaginitis, mild severity.
• ICD-10 Code: A59.01.
• Contributing factors: Recent unprotected sexual activity.
• No evidence of concurrent sexually transmitted infections.

Plan:

• Initiate metronidazole 500 mg orally twice daily for 7 days.
• Educate patient on safe sexual practices and the importance of partner treatment.
• Schedule follow-up in 1 week to assess treatment response.
• Consider testing for other STIs if symptoms persist.

Treatment & Plan Section for ICD-10 Code A59.01 – Trichomonal vulvovaginitis

• First-line treatment with metronidazole or tinidazole.
• Patient education on the importance of partner treatment.
• Monitoring for symptom resolution and potential reinfection.
• Follow-up appointment to reassess and manage any complications.

Using ICD-10 Code A59.01 for Trichomonal vulvovaginitis in Billing & SOAP Note Compliance

• Select appropriate ICD-10 code based on clinical findings and documentation.
• Ensure Subjective (S) and Objective (O) sections reflect the diagnosis accurately.
• Align treatment plans with clinical guidelines to support justified billing.
• Document any additional services provided during the visit for comprehensive billing.

Related ICD-10 Codes Often Used with Trichomonal vulvovaginitis

• A59.00 – Trichomonal infection, unspecified site
• A54.9 – Gonococcal infection, unspecified
• A56.9 – Other sexually transmitted infections, unspecified
• N76.0 – Acute vaginitis

ICD-10 Code A59.01 in Medical Billing and Insurance for Trichomonal vulvovaginitis

ICD-10 Code A59.01 is crucial for accurate billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant patient history and symptoms to support the diagnosis.
• Use the code in conjunction with other relevant codes for comprehensive billing.
• Ensure that the treatment plan aligns with the diagnosis for reimbursement purposes.

Common CPT Pairings: