Ob-Gyn Coding Alert

Forget 625.9; you should be using one of two codes instead.

Patients often present to an ob-gyn practice complaining of pelvic pain or pain in the perineal, vulvar, vaginal, uterine or ovarian area. This mostly occurs in the lower abdominal area. It might be steady, or it may come and go.

In the past, you reported 625.9 (Unspecified symptom associated with female genital organs). Here are two codes you should using to report this condition now:

• R10.2, Pelvic and perineal pain
• N94.89, Other specified conditions associated with female genital organs and menstrual cycle.

You have a specific code for pelvic and perineal pain, vaginal pain, or adnexal pain (R10.2) and a not so specific code (N94.89) to report female genital organ pain that is not elsewhere classified.

Documentation: Your provider should specify the pain’s location to assign the correct code. You might have other areas of pain, such as abdominal pain and tenderness, which would direct you to other codes.

Here’s how you’ll locate this code in your Alphabetic Index:

Neuralgia, neuralgic (acute) M79.2

-               perineum R10.2

-               pubic region R10.2

Pain(s) (see also Painful) R52

- abdominal R10.9

- - lower R10.30

- - - pelvic or perineal R10.2

-               adnexa (uteri) R10.2

- broad ligament R10.2

- female genital organs NEC N94.89

- genital organ

- - female N94.89

- ovary N94.89

-               pelvic (female) R10.2

- perineal, perineum R10.2

-               round ligament (stretch) R10.2

-               - uterus NEC N94.89

- vagina R10.2

- vulva R10.2

Symptoms NEC R68.89

- genital organs, female R10.2

- pelvis NEC, female R10.2

Coder tips: You’ll see excludes notes under the category title R10- (Abdominal and pelvic pain) which forbids you from reporting these codes with renal colic (N23). You might report these codes with dorsalgia (M54-) or flatulence and related conditions (R14-), but it isn’t likely.