ICD-10 Code A60.04 | Herpesviral vulvovaginitis Symptoms, Diagnosis, Billing

Herpesviral vulvovaginitis is an inflammatory condition of the vulva and vagina caused by herpes simplex virus (HSV). It is clinically significant due to its potential for recurrent episodes and complications, including secondary infections. Accurate coding with ICD-10 Code A60.04 facilitates proper diagnosis, documentation, medical billing, and public health reporting, ensuring effective management of this infectious disease.

What is ICD-10 Code A60.04 for Herpesviral vulvovaginitis?

ICD-10 Code A60.04 specifically denotes herpesviral vulvovaginitis, an infection characterized by inflammation of the vulva and vagina due to herpes simplex virus. This code should be utilized in clinical documentation and billing when diagnosing patients presenting with symptoms such as vulvar lesions, itching, and discharge, ensuring accurate representation of the patient's condition.

ICD-10 Code A60.04 – Clinical Definition and Explanation of Herpesviral vulvovaginitis

Herpesviral vulvovaginitis is primarily caused by the herpes simplex virus, which can lead to painful lesions and inflammation in the genital area. The condition may progress to recurrent outbreaks, necessitating medical attention to manage symptoms and prevent complications.

Key Clinical Features:

• Presence of painful vesicular lesions on the vulva and vagina.
• Symptoms of itching, burning, and dysuria.
• Potential for recurrent episodes following initial infection.
• Increased risk of secondary bacterial infections.

ICD-10 Code A60.04 for Herpesviral vulvovaginitis – SOAP Notes & Clinical Use

ICD-10 Code A60.04 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plan for herpesviral vulvovaginitis. This code is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition.

What Does ICD-10 Code A60.04 for Herpesviral vulvovaginitis Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A60.04 connects subjective patient-reported symptoms with objective clinical findings, facilitating 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 A60.04 – Herpesviral vulvovaginitis

Herpesviral vulvovaginitis requires prompt medical intervention to alleviate symptoms and prevent complications. Treatment may include antiviral medications and supportive care.

Antibiotic Therapy:

• Acyclovir: 400 mg orally three times daily for 7-10 days.
• Valacyclovir: 1 g orally twice daily for 7-10 days.
• Famciclovir: 250 mg orally three times daily for 7-10 days.

Supportive Care:

• Topical anesthetics to relieve pain.
• Sitz baths to soothe irritation.
• Avoidance of irritants such as soaps and douches.

Infection Control:

• Educate patients on safe sexual practices.
• Encourage disclosure of HSV status to partners.
• Implement precautions during outbreaks to prevent transmission.

How to Document Symptoms of Herpesviral vulvovaginitis (ICD-10 A60.04) in SOAP Notes

Subjective:

• Patient reports painful vulvar lesions and itching.
• History of recurrent genital herpes outbreaks.
• Symptoms began 3 days prior to the visit.
• Denies fever or systemic symptoms.

Objective:

• Vesicular lesions observed on the vulva.
• Erythema and edema noted in the affected area.
• No signs of secondary bacterial infection.
• Vital signs within normal limits.

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SOAP Note Guidelines for Diagnosing Herpesviral vulvovaginitis (ICD-10 Code A60.04)

Assessment:

• Diagnosis: Herpesviral vulvovaginitis, mild severity.
• ICD-10 Code: A60.04.
• Triggers: Recent sexual activity and stress.
• Patient education on managing outbreaks provided.

Plan:

• Initiate antiviral therapy with Acyclovir.
• Recommend topical anesthetics for symptom relief.
• Schedule follow-up in 1 week to assess treatment response.
• Educate on safe sexual practices and outbreak management.

Treatment & Plan Section for ICD-10 Code A60.04 – Herpesviral vulvovaginitis

• First-line antiviral treatments include Acyclovir or Valacyclovir.
• Non-pharmacologic strategies include warm sitz baths and topical anesthetics.
• Monitor for symptom resolution and potential complications.
• Follow-up appointments should be scheduled to reassess the condition.

Using ICD-10 Code A60.04 for Herpesviral vulvovaginitis in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings in SOAP notes.
• Use the code in appropriate clinical settings, including outpatient and emergency care.
• Align treatment plans with clinical guidelines to support justified billing.
• Document any relevant comorbidities or complications to enhance coding accuracy.

Related ICD-10 Codes Often Used with Herpesviral vulvovaginitis

• A60.00 – Herpesviral infection of unspecified site
• A60.01 – Herpesviral infection of the anus
• A60.02 – Herpesviral infection of the vulva
• A60.03 – Herpesviral infection of the vagina

ICD-10 Code A60.04 in Medical Billing and Insurance for Herpesviral vulvovaginitis

ICD-10 Code A60.04 is crucial for billing in hospital, ER, or infectious disease care settings, ensuring accurate reimbursement for services rendered.

Billing Notes:

• Document all relevant patient history and clinical findings to support the use of this code.
• Utilize the code in both inpatient and outpatient settings for comprehensive billing.
• Ensure that the diagnosis aligns with the treatment provided to facilitate claim approval.

Common CPT Pairings: