Wiki help on ICD-10 only, plese

[AgnieszkaLakritz]

Pre-op Diagnosis: dysmenorrhea, uterine fibroids
Post-op Diagnosis: Same
Procedure: Laparoscopic Assisted Vaginal Hysterectomy with right salpingoopherectomy

Findings: Enlarged bulky fibroid uterus with adhesion of omentum to left cornua. Uterus weight 220 grams.

 

[Mayzoo]

You do not code symptoms of a diagnosis. However, you need to know if the dysmenorrhea is a symptom of the uterine fibroids or not:


Dysmenorrhea

Dysmenorrhea, also known as menstrual cramps, is a condition that includes pain right before and during menstruation that can range from mild to severe. The types of pain that are associated with dysmenorrhea include sharp, burning, throbbing, dull, burning, or shooting in the hips, lower back, or inner thighs. Other symptoms that can accompany dysmenorrhea include vomiting or diarrhea.

The term primary dysmenorrhea is used to describe menstrual cramps that occur without an identifiable cause other than menstruation, while secondary dysmenorrhea is caused by something other than menstruation. Secondary dysmenorrhea can be caused by endometriosis, ovarian cysts, fibroids, cervical or uterine polyps, pelvic infections, or structural problems in a woman’s uterus, cervix, or vagina.

https://www.gwdocs.com/specialties/obstetrics-gynecology-ob-gyn-/fibroid-menstrual-disorders/


Either you need to see if clarification is in the rest OP report, or query the doc OR it is a possible a more experienced coder (I'm still new) would know if the doc would list secondary dysmenorrhea in this fashion.

 

[AgnieszkaLakritz]

You do not code symptoms of a diagnosis. However, you need to know if the dysmenorrhea is a symptom of the uterine fibroids or not:


Dysmenorrhea

Dysmenorrhea, also known as menstrual cramps, is a condition that includes pain right before and during menstruation that can range from mild to severe. The types of pain that are associated with dysmenorrhea include sharp, burning, throbbing, dull, burning, or shooting in the hips, lower back, or inner thighs. Other symptoms that can accompany dysmenorrhea include vomiting or diarrhea.

The term primary dysmenorrhea is used to describe menstrual cramps that occur without an identifiable cause other than menstruation, while secondary dysmenorrhea is caused by something other than menstruation. Secondary dysmenorrhea can be caused by endometriosis, ovarian cysts, fibroids, cervical or uterine polyps, pelvic infections, or structural problems in a woman’s uterus, cervix, or vagina.

https://www.gwdocs.com/specialties/obstetrics-gynecology-ob-gyn-/fibroid-menstrual-disorders/


Either you need to see if clarification is in the rest OP report, or query the doc OR it is a possible a more experienced coder (I'm still new) would know if the doc would list secondary dysmenorrhea in this fashion.

Thank you so much for your response. I was doing research yesterday and indeed I find codes for primary and secondary dysmenorrhea. In this case secondary may be appropriate since fibroids are reported.

 

[Mayzoo]

A more experienced coder responds I hope, but you should never guess or surmise when coding a diagnosis. You would likely need to query the provider for clarity, then the query form and response become part of the medical record for that patient.

 

[thomas7331]

Pre-op Diagnosis: dysmenorrhea, uterine fibroids
Post-op Diagnosis: Same
Procedure: Laparoscopic Assisted Vaginal Hysterectomy with right salpingoopherectomy

Findings: Enlarged bulky fibroid uterus with adhesion of omentum to left cornua. Uterus weight 220 grams.

The ICD-10 alphabetic index will take you to correct codes with all of the information that you have here.
I would code this as follows:

Dysmenorrhea: N94.6 - Dysmenorrhea, unspecified
Fibroids, uterus: D25.9 - Leiomyoma of uterus, unspecified
Adhesion, omentum, to uterus: N73.6 - Female pelvic peritoneal adhesions (postinfective)

I agree with the post above that you can't assume that the dysmenorrhea is secondary, or just a symptom, since it is not documented as such and the provider has not stated that fibroids is the cause. However, I would not query the provider since you can code this accurately based on the documentation that you already have. I'd note that you haven't included the procedure note itself and I would recommend not just coding off of the headers because the provider's procedure documentation will often include essential information that can affect your code choices.

 

[AgnieszkaLakritz]

I came with the same answers at first and the facility the I submit the answers ( test purpose) didn't like that. I was perplexed because I saw no reason to be wrong , only the dysmenorrhea code.
Thank you for response!

The ICD-10 alphabetic index will take you to correct codes with all of the information that you have here.
I would code this as follows:

Dysmenorrhea: N94.6 - Dysmenorrhea, unspecified
Fibroids, uterus: D25.9 - Leiomyoma of uterus, unspecified
Adhesion, omentum, to uterus: N73.6 - Female pelvic peritoneal adhesions (postinfective)

I agree with the post above that you can't assume that the dysmenorrhea is secondary, or just a symptom, since it is not documented as such and the provider has not stated that fibroids is the cause. However, I would not query the provider since you can code this accurately based on the documentation that you already have. I'd note that you haven't included the procedure note itself and I would recommend not just coding off of the headers because the provider's procedure documentation will often include essential information that can affect your code choices.