Ob-Gyn Coding Alert

Receiving a denial because of an incorrect diagnosis code can be costly, time consuming, and downright frustrating. But ensuring that the diagnosis code for female genital organ pain or bleeding is correct can be difficult. This difficulty arises from the fact that often these female problems are not attributable to any specific disease processes and require the coding of signs and symptoms. However, instead of turning to the special section in the ICD-9-CM for symptoms (sections 780-799), ob/gyn coders need to use a special section that covers symptoms and disorders of the female genital organs and the natural functions of menstruation and menopause (codes 625-627). For correct selection these codes require a sound understanding of terminology and clinical manifestations. With the clinical help of womens health nurse practitioner Linda Dominguez, RN-C, from Albuquerque, NM, this article reviews each of the codes and is designed to assist the ob/gyn coder in choosing correct codes the first time through.

Pain and Other Symptoms

The codes in section 625 (pain and other symptoms associated with female genital organs) include everything from painful intercourse to female stress incontinence.

625.0: Dyspareunia is the medical name for painful intercourse. This code covers painful intercourse at any age and pain that occurs during or after intercourse. The pain may be felt deep in the pelvic region, in the vagina itself, or superficially. Both physical and/or psychological factors can contribute to or cause dyspareunia. For psychogenic dyspareunia, code 302.76 (psychosexual dysfunction with functional dyspareunia).

Note: It is not recommended that ob/gyn practices use the codes for psychogenic disorders because many payers will not pay for the mental disorder codes unless you are a mental health care provider.

625.1: Vaginismus is the involuntary spasm of the muscles surrounding the vaginal opening. This spasm can cause the vagina to close so tightly that it is impossible for intercourse or the insertion of tampons or medical instruments. This disorder is also called colpospasm or vulvismus. If the cause is psychogenic, use code 306.51 (psychogenic vaginismus).

625.2: Mittelschmerz is a German term that simply means middle pain. This code is for abdominal pain occurring from the site of ovulation and at time of ovulation or in the middle of the menstrual cycle.

625.3: Dysmenorrhea is a commonly used code for painful menstruation, including cramps. Again, if the painful menstruation is of a psychogenic nature, use 306.52 (psychogenic dysmenorrhea).

625.4: Premenstrual tension syndrome. This code is to be used for premenstrual symptoms, including headaches. The term molimen in the code description means the effort to establish normal menstrual flow.

625.5: Pelvic congestion syndrome (also referred to as Taylors syndrome or congestion fibrosis syndrome) refers to a complex of symptoms caused by abnormalities within the ovarian veins. In pelvic congestion syndrome, the ovarian veins are abnormally dilated (wide) and/or the valves do not work properly, allowing blood to flow backward and pool in certain areas. The condition is similar to varicose veins, which are sometimes seen in the legs. Patients with pelvic congestion syndrome may experience heaviness or a burning or throbbing pain in the abdomen and lower back. The pain is generally most severe prior to the onset of menstruation and is exacerbated by sexual intercourse or by standing for long periods of time. Some patients also experience menstrual abnormalities, chronic fatigue, urinary urgency, and irritable bowel syndrome.

625.6: Stress incontinence, female. This code is only for the involuntary escape of urine at times of abdominal or pelvic stress, such as coughing, sneezing, exercise or laughing. Mixed incontinence (788.33) includes both stress and urge (involuntary escape of urine associated with the urge to urinate) incontinence.

Note: The coder may encounter a diagnosis of pelvic pain. This is a problem that often affects women of all ages and is sometimes difficult to link to the menstrual cycle. Frequently, pelvic pain is a result of adhesions or endometriosis, but not always. There is not a specific code for this disorder, but ICD-9-CM references the code 625.9 for pelvic pain. In addition, if the physician mentions any of the following types of pain (adnexal [uteri] pain, genital organ pain, ovarian pain, perineum pain, round ligament pain, uterine pain, vaginal pain or vulvar pain), code 625.9 would also be reported in the absence of a more specific cause for the pain.

Disorders of Menstruation/Abnormal Bleeding

The codes in section 626 (disorder of menstruation and other abnormal bleeding from female genital tract) cover bleeding symptoms with the exception of those associated with menopause or postmenopause. Coders need to be familiar with all the descriptive terms that may be used to describe bleeding.

626.0: Amenorrhea is a term used to describe the absence of menstruation. It is further broken down into primary or secondary. Primary amenorrhea refers to having never experienced menses. Secondary amenorrhea refers to the absence of menses for three to six months after having had a least one menses.

626.1: Scant or infrequent menstruation is referred to as hypomenorrhea (decreased amount of uterine bleeding that occurs at regular intervals) and oligomenorrhea (irregular bleeding episodes that occur at intervals of more than 42 days).

626.2: Excessive or frequent menstruation is referred to as heavy periods, menorrhagia (uterine bleeding at the usual time of menses that is excessive in either the amount or duration of flow), menometrorrhagia (frequent, irregular bleeding that may be excessive in amount or of prolonged duration) or polymenorrhea (frequent periods). This code does not include puberty bleeding or heavy premenopausal bleeding.

626.3: Puberty bleeding is the code to be use for excessive bleeding associated with the onset of menstrual periods and is often referred to as pubertal menorrhagia.

626.4: Irregular menstrual cycle. An average cycle is 28 days, but anywhere from 23 to 35 days is considered normal. This code would be for reporting irregularities beyond what is considered normal.

626.5: Ovulation bleeding is considered regular bleeding that occurs in the middle of the menstrual cycle or at the time of ovulation.

626.6: Metrorrhagia is a term that refers to bleeding between periods and may be used if the bleeding is not considered ovulation bleeding or postcoital.

626.7: Postcoital bleeding is bleeding from the vagina following intercourse.

Note: The coder may encounter a diagnosis of dysfunctional uterine bleeding or DUB. This is a problem that often affects women as they start to get periods and as they get closer to menopausealthough any woman who menstruates can experience DUB. The main symptoms are prolonged and/or irregular menstrual bleeding. There is not a specific code for this disorder although the nonspecific code in this section 628.8 (other) has a description for dysfunctional or functional uterine hemorrhage. Because this is a nonspecific code, some coders may decide to use 626.6 for metrorrhagia. Note, however, that doing so alters the physicians stated finding and, according to NCHS ICD-9-CM staff, would represent inaccurate coding. There is also a code (626.9) for unspecified female genital bleeding, which can be used when none of the other codes are appropriate.

Menopausal Disorders

Section 627 (menopausal and postmenopausal disorders) covers many of the symptoms and disorders covered in sections 625 and 626 but with menopause as the contributing factor. The cessation of menses for at least 12 months constitutes menopause.

627.0: Premenopausal menorrhagia refers to the irregular and scanty to heavy bleeding that occurs with the onset of menopause. Coders may find that this bleeding is referred to using the term climacteric, which simply refers to the period that marks the cessation of a womans reproductive ability.

627.1: Postmenopausal bleeding is any bleeding that occurs following a womans cessation of menses.

627.2: Menopausal or female climacteric states. This code covers the wide range of bodily symptoms a woman may experience during menopause. These symptoms include hot flashes, insomnia, headaches and lack of concentration.

627.3: Postmenopausal atrophic vaginitis is a skin condition of the vulva and vagina. It occurs when estrogen is lacking in the body causing skin changes, especially in the vulvar and vaginal areas, as well as the urethra and bladder. With these changes, the skin becomes thin and is more easily injured. The common signs and symptoms include: vaginal dryness, vulvar itching and/or burning, problems with urination, such as burning, frequency, urgency, loss of urine and pain. It can also cause bleeding and spotting and pain with intercourse.

627.4: States associated with artificial menopause. Artificial menopause refers to menopause that is induced by surgical removal of the ovaries or by other artificial impairment of the ovaries from drugs, chemotherapy or radiation. All of the symptoms associated with natural menopause may be experienced in artificial menopause, and coders should use this code instead of those listed above for natural menopause. Premature menopause due to ovarian failure should be coded using 256.3 (other ovarian failure).

Finally, this section also includes two nonspecific codes:
627.8 for specified menopausal and postmenopausal disorders and 627.9 for those unspecified.