ICD-10 Code B37.31 | Acute candidiasis of vulva and vagina Symptoms, Diagnosis, Billing

Acute candidiasis of the vulva and vagina is a fungal infection caused by Candida species, primarily Candida albicans. It is characterized by inflammation, itching, and discharge, and is clinically significant due to its prevalence among women of reproductive age. Accurate coding with ICD-10 Code B37.31 ensures proper diagnosis, documentation, and billing, facilitating effective public health reporting and management of this common condition.

What is ICD-10 Code B37.31 for Acute candidiasis of vulva and vagina?

ICD-10 Code B37.31 represents acute candidiasis of the vulva and vagina, a common yeast infection caused by an overgrowth of Candida species. This code should be used in clinical documentation when diagnosing patients presenting with symptoms such as itching, burning, and abnormal discharge. Proper use of this code is essential for accurate billing and to reflect the patient's condition in medical records.

ICD-10 Code B37.31 – Clinical Definition and Explanation of Acute candidiasis of vulva and vagina

Acute candidiasis of the vulva and vagina is primarily caused by an imbalance in the normal flora, leading to an overgrowth of Candida. Risk factors include antibiotic use, diabetes, and immunosuppression. Prompt medical attention is necessary to alleviate symptoms and prevent complications.

Key Clinical Features:

• Intense itching and irritation in the vulvar area.
• Thick, white vaginal discharge resembling cottage cheese.
• Erythema and swelling of the vulva and vagina.
• Pain during intercourse or urination.

ICD-10 Code B37.31 for Acute candidiasis of vulva and vagina – SOAP Notes & Clinical Use

ICD-10 Code B37.31 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plan. 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 B37.31 for Acute candidiasis of vulva and vagina Mean in SOAP Notes?

In SOAP notes, ICD-10 Code B37.31 connects subjective reports of symptoms with objective clinical findings, leading to a formal diagnosis. This code supports continuity of care, aids in billing processes, and meets EHR documentation standards.

Treatment Options for ICD-10 Code B37.31 – Acute candidiasis of vulva and vagina

Acute candidiasis requires prompt treatment to alleviate symptoms and prevent recurrence. Antifungal therapy is the primary treatment approach.

Antibiotic Therapy:

• Fluconazole 150 mg orally as a single dose.
• Clotrimazole 1% cream applied topically for 7 days.
• Miconazole 2% cream applied topically for 7 days.

Supportive Care:

• Maintain proper hygiene and dry the affected area.
• Avoid irritants such as scented soaps and douches.
• Wear breathable cotton underwear to reduce moisture.

Infection Control:

• Educate patients on avoiding sexual intercourse until treatment is complete.
• Advise on proper hand hygiene to prevent spread.
• Encourage partners to seek evaluation if symptoms are present.

How to Document Symptoms of Acute candidiasis of vulva and vagina (ICD-10 B37.31) in SOAP Notes

Subjective:

• Patient reports intense itching and burning in the vaginal area.
• History of recent antibiotic use.
• Complaints of thick, white discharge.
• Symptoms worsened after sexual intercourse.

Objective:

• Erythema and edema observed on vulvar examination.
• Presence of thick, white discharge on speculum exam.
• No signs of other infections noted.
• Vital signs within normal limits.

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SOAP Note Guidelines for Diagnosing Acute candidiasis of vulva and vagina (ICD-10 Code B37.31)

Assessment:

• Diagnosis: Acute candidiasis of vulva and vagina, mild severity.
• ICD-10 Code: B37.31.
• Contributing factors: Recent antibiotic therapy and diabetes.
• No signs of systemic infection.

Plan:

• Initiate treatment with fluconazole 150 mg orally.
• Educate patient on hygiene practices and symptom management.
• Schedule follow-up in one week to assess treatment response.
• Consider referral to a specialist if symptoms persist.

Treatment & Plan Section for ICD-10 Code B37.31 – Acute candidiasis of vulva and vagina

• First-line treatment includes fluconazole or topical antifungals.
• Non-pharmacologic strategies include maintaining proper hygiene and avoiding irritants.
• Monitor treatment response and educate on symptom recognition.
• Follow-up appointments should be scheduled to ensure resolution of symptoms.

Using ICD-10 Code B37.31 for Acute candidiasis of vulva and vagina 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 inpatient 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 Acute candidiasis of vulva and vagina

• B37.0 – Candidiasis of mouth and throat
• B37.9 – Candidiasis, unspecified

ICD-10 Code B37.31 in Medical Billing and Insurance for Acute candidiasis of vulva and vagina

ICD-10 Code B37.31 is crucial for billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant symptoms and treatment plans to support the claim.
• Use the code in settings where acute candidiasis is diagnosed and treated.
• Ensure that the patient's medical history is accurately reflected in the documentation.
• Include any relevant lab results that support the diagnosis.

Common CPT Pairings: