2025 ICD-10-CM code N94.810
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Diseases of the genitourinary system - Noninflammatory disorders of female genital tract (N80-N98) Diseases of the genitourinary system (N00-N99) Feed
Vulvar vestibulitis, characterized by pain in the vulvar vestibule, often triggered by touch or pressure.
Modifiers may be applicable depending on the circumstances of the visit and the services performed. Consult current coding guidelines.
Medical necessity is established by the presence of clinically significant vulvar pain that significantly impacts the patient's quality of life, interferes with daily activities, or requires medical intervention for relief.Diagnosis should be confirmed via clinical evaluation.Treatment may include medication, physical therapy, or surgical intervention in cases that do not respond to conservative management.
Gynecologist, potentially with input from other specialists depending on the complexity of the case and co-morbidities.
In simple words: Vulvar vestibulitis is pain in the area around the opening of the vagina. This pain can be triggered by things like sex, using tampons, or even sitting down.It can also cause a burning or stinging sensation. The cause isn't always clear, but it often gets better with treatment.
Vulvar vestibulitis (also known as vestibulodynia or vestibular adenitis) is a subtype of vulvodynia, specifically localized to the vulvar vestibule.It presents with severe pain during vaginal entry (intercourse, tampon insertion), tenderness to pressure in the vestibule, and sometimes redness of the vestibule.The pain can be constant or provoked by touch, pressure (sitting, tight clothing), or sexual activity. The etiology is not fully understood but may involve nerve overactivity, hormonal imbalances, or other underlying conditions.It is important to note that while the term historically implied inflammation, there's limited evidence supporting this.
Example 1: A 30-year-old woman presents with severe pain during intercourse and tampon insertion, localized to the vaginal opening. Examination reveals tenderness and slight redness of the vulvar vestibule.Diagnosis: Vulvar vestibulitis., A 45-year-old postmenopausal woman reports persistent burning and irritation at the vaginal opening, worsened by sitting for prolonged periods.Pelvic exam shows no infection but some dryness and tenderness to touch in the vestibule.Diagnosis: Vulvar vestibulitis, possibly exacerbated by estrogen deficiency., A 25-year-old woman experiences intense pain during sexual activity. She reports no other symptoms.A thorough exam shows localized tenderness to touch in the vulvar vestibule. Diagnosis: Vulvar vestibulitis.
Detailed history of symptoms (onset, duration, character, triggers), physical examination findings (including specific location of pain, presence of redness or inflammation), results of any diagnostic tests (e.g., cultures to rule out infections), and treatment plan.Patient-reported pain scales are valuable.
** Vulvar vestibulitis can significantly impact a woman's quality of life and sexual health.It is important to approach this diagnosis with empathy and provide comprehensive management.
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- Payment Status: Active
- Modifier TC rule: Not applicable.This is a diagnostic code.
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- Specialties:Gynecology
- Place of Service:Office, Outpatient clinic