N76.81 — Mucositis (ulcerative) of vagina and vulva
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Record of specimen type as fresh vaginal discharge.
- Documented pH value (numeric) when pH testing performed.
- Microscopy findings from both saline and KOH preparations, including presence/absence of motile T. vaginalis, clue cells, yeast, and white blood cells.
- Result of whiff/amine test when performed.
Key Coverage Criteria
- Diagnostic testing to identify the etiology of signs and symptoms of vaginitis in members/enrollees aged ≥16 years.
- Use of unspecified amplified DNA probe testing for evaluation of genitourinary conditions when performed as part of the diagnostic workup for vaginitis or other genitourinary infections.
- KOH “whiff” (amine odor) test for symptomatic individuals ≥16 years for evaluation of vaginitis
- Assay for sialidase activity for symptomatic individuals ≥16 years for evaluation of vaginitis
- Direct and amplified DNA probe tests to detect Candida and Gardnerella vaginalis for symptomatic individuals ≥16 years for evaluation of vaginitis
- pH testing of vaginal discharge to assist in evaluation of vaginal symptoms; an elevated pH (>4.5) is commonly associated with bacterial vaginosis (BV) or Trichomonas vaginalis.
1 Active Policy
AMBETTER-CP.MP.97 — Testing for Select Genitourinary Conditions
Related Codes
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