# Menses suppression in CP female



## debrowne (Dec 15, 2010)

Does anyone know which ICD9 code to use when depo provera is being used to suppress menses in a wheelchair bound teenager with cerebral palsy? Any assistance would be greatly appreciated. Donna


----------



## btadlock1 (Dec 15, 2010)

V25.3 - Menstrual Extraction (regulation)
V25.02 - Initiation of other contraceptive measures
V25.9 - Unspecified contraceptive management

I'd go with one of those...


----------



## preserene (Dec 15, 2010)

ICD 9 gives suppression of menstruation on to 626.8. I feel this holds good as for the reason for Suppression- therapeutic, induction, or any other reason not mentioned.
here it is for threraputic purpose of suppression for an adolescent  CP; meaning, creating a disorder.
I think with this code and a secondary code for CP, along with physician report indicating why it is suppressed would go well. 
Menstrual Regulation is evacuating the uterus for persons who have a short period of amenorrhea in early pregnancy.- a kind of an abortion procedure
By definition and stricly speaking, Menstrual regulation" (MR) or "menstrual extraction" (ME) are synonyms for an abortion procedure that is especially suited to circumventing the abortion laws of developing countries, because the abortions are performed so early that the "evidence" which results is either destroyed during the procedure or easily disposed of.
*So it is not for suppressing the menstruation *.

Secondly, it is not for "contraception" directly the supressing is undertaken for this girl; it for relieving her with all the ordeals she has to undergo with the menstrual process with the condition of CP though it could be one reason though. I fear whether we can admittedly and openly give this "contraception'' as the primary focus for suppressing or inducing amennorrhoeic status  in her.

Does this explanation make some sense?


----------



## msrd_081002 (Dec 16, 2010)

*RE: ICD/Depo (contraceptive)for supression of menses/CP*

I'll assign the following:

If initial visit:
V25.02+343.9 + V46.3

If subsequent  f/up visit
V25.49+343.9 + V46.3
-----------------------------------------------
Initial depo-  v25.02 PDX
f/u depo-v25.49 PDX
wheelchair dependence= V46.3 (coded to reflect the disabilty/necessitated depo contraceptive)
-------------------------------------------------------------
PS:

The *Coding Clinic *Third Quarter, 1997 says to assign code V25.02 (encounter for contraceptive management, initiation of other contraceptive measures) for the *initial Depo-provera injection *and code *V25.49 (contraceptive management, other method) for subsequent follow-up visits. *
--------------------------------------------------------------------------------------------------------
I'd NOT agree with 626.8 bcoz it is "NOT iatrogenic( depo-induced)".The *intent* of depo is "to supress the menses". The pt is NOT with ANY "suppression of menses complaint".

Thanks


----------



## btadlock1 (Dec 16, 2010)

I agree with msrd_081002. I wouldn't have selected a diagnosis from the disease/injury sections, because the patient wasn't being seen to treat a problematic or malfunctioning uterus/menstruation cycle. This seems to fit more with a V-code, according to ICD-9 conventions. The medication is _primarily_ a contraceptive, even if it's not being used to prevent pregnancy, and the patient, who is otherwise asymptomatic (in regards to her reproductive system), is encountering health services for elective treatment using the drug. 

I did struggle with this one - I was really leaning towards procreative management as well, but that seemed a little too focused on fertility to really fit. I ended up deciding that the patient is undergoing management of a contraceptive, regardless of what the contraceptive's overall purpose is.


----------



## preserene (Dec 16, 2010)

Every one has the right to have their own views. But what our coding manual narrates to us is the most important.

It  seems as “Suppression *of *“Menstruation Vs “suppre*ssed* Menstruation”: 

A  failure of menstruation to occur when expected, as in amenorrhea, *or menstruation that is suppressed, as with Gn Rit agonists ,which is called  suppression of menses. * 
Indegeous(invivo hormonal status) suppressed menstruation-  what happens ?-when FSH and LH are suppressed, the chances of ovulation and therefore ... ovulation suppression
The a*ct of  “Suppression  of” *menstruation can be beneficial in prevention or treatment of several medical conditions. The mechanism involves a reduction in the volume and frequency of uterine bleeding or a reduction in normal cyclic hormonal fluctuations.. We are dealing with “reduction in normal cycle hormonal fluctuation in our ’ case study’.
So,OUR ICD code MANUAL STATEMENT is correct in stating  the word “ *Suppression of *“ ,(not specific as “Suppressed state” as you interpret), which holds good for coding purpose. By the way, the term suppression of menstruation is  in vogue by the obgyn practice for the “of” rather than “-pressed”.
Thank you and no more discussion from my side on this . Bye


----------



## btadlock1 (Dec 16, 2010)

My ICD-9 has a note under 626.8 that says "Other specified irregular menstruation". I wouldn't feel comfortable assigning a code from the subsection "Disorders of menstruation and other abnormal bleeding from female genital tract", in the absence of any such disorder. So, I'll agree to disagree with you on this one.


----------



## ohn0disaster (Dec 16, 2010)

I agree with msrd_081002, 100%. The patient's suppression of menses is forced, by way of depo-provera. It is not a naturally occuring disorder with the patient. It is purposely being done for patient comfort, well being, and due to concerns related to hygiene and problems coping. Menses can be difficult to manage in some adolescent girls with CP. Difficulties may arise in managing hygiene by the adolescent or family. Dysphoria/irritability/cramping or heavy periods may occur, as in any adolescent population, and some girls experience exacerbation of their seizure disorder with the menstrual cycle.

If the suppression of menses were naturally occuring in this patient, 626.8 could be considered, but that is not the case. However, *secondary amenorrhea* is where an established menstruation has ceased - for three months in a woman with a history of regular cyclic bleeding, or six months in a woman with a history of irregular periods. Secondary amenorrhea, 626.0, does encompass the drug-induced suppression of menstruation, but this is AFTER the depo-provera is shown to have worked in suppression for 3-6 months, depending on the situation.

For more information please see: http://misc.thefullwiki.org/Amenorrhea


----------



## preserene (Dec 16, 2010)

Now I am sorry I have to come back.
Your argument not to place the” suppression of menstruation”  in the diagnosis code 626.8   is baseless. It is THE DOCUMENTED DIAGNOSIS AND THE TERMINOLOGY IN THIS CASE.
Well, in my OBGYN career of  30yrs , me or any OBGYN giving a diagnosis of  “suppression of” menstruation as a diseased condition, though it makes sense to include  suppressed condition too. It is only documented as a necessity or perfoming as an act of  SUPPRESSION OF MENSTRUATION. That is the way it is placed in the ICD-9 code too after careful thoughts and the panel acceptance with many thoughts from AMA . The act of producing a condition  of “suppression of menstruation” itself SUFFICE to report it with 626.8, irrespective of the induced condition in otherwise normally menstruating who needs the medical intervention .
You kindly read my previous post and if you do not understand it the way it should be, take as the manual says. If not agreeing, clarify with any OBGYN PHYSICIAN /CONSULTANT.
Then diagnosis of suppression of Menstruation is given by the physician when the necessity for suppression sets in, not by you and me.
The *natural suppression *by  bodily hormones *usually goes with the term  “delayed period”, *if it does not meet the secondary amennorrhea criteria which is defined  as the absence of mensus for 6 months (or greater than three times the previous cycle intervals) in a woman who had been menstruating before.  AND FOR YOUR KIND INFORMATION, IT DOES NOT GO WITH THE TERM “SUPPRESSTION  OF MENSTRUATION” diagnosis by and large by the physicians and their documentation
The term Suppression Of Menstruation is universally and commonly accepted and used in practice by the OBGYN exclusively for creating/producing  a condition of suppression of already menstruating women for some reason and that is how the AMA has placed the term “suppression of “ menstruation into that category though it is an induced status,(with no other place being given) whether it is  a mis- norm or misplaced, as per your concept, to be there ; it is to be accepted for coding purpose too in such scenario.

Hi, there, don't extend to say I AM STUCK with the word. Yes as a medical  professionalist, I have to be detailed so, because it is a human life we are dealing with and we cannot slack or afford to have any morbidity or mortality on any account.That is MEDICINE AND THE HEALTH PROFESSION. So also I wish to carry on with the payment system with minor details being given importance


----------



## btadlock1 (Dec 16, 2010)

Baseless? No. First of all, the exact terminology used in the note is not available. If you'd refer to the original post, it is paraphrased. Only debrowne knows what the note says. The only diagnosis _documented_ is CP. The patient is not *receiving treatment *for menses which are currently suppressed, as would be indicated by assigning a diagnosis of "suppression of menstruation". They fit in perfectly with the primary circumstances for the use of V-codes, located in Section 1, Chapter 18 of the ICD-9 coding conventions. Of particular significance is the note on #2: "A diagnosis/symptom code should be used whenever a *current, acute diagnosis is being treated, or a sign or symptom is being studied*."
To assign a diagnosis/symptom code is to state that the patient is currently afflicted with that condition, *not that they are in the office to have that condition established*. 

I'm not questioning your 30 years experience; you've been coding longer than I've been alive. You and I may have a fundamental disagreement on the symantics of this issue, but I'm sticking to my guns on this one. It's perfectly possible that I'm dead wrong about this, but I feel strongly that this particular situation warrants the assignment of a V-Code, based on my understanding of ICD-9 guidelines.


----------



## preserene (Dec 16, 2010)

I was never ever against the V code. It has its validation and merits here.You go thro' my first few posts you would  understand that. My stand is for the diagnosis of suppression of Menstruation. Well the patient encounter to the OBGYN is for the very purpose of suppression of menses; the CP diagnosis and other stuff are secondary.
Here the problem is the menstruation which is an unwanted condition ,meaning, the very normality is an abnormal phenomenon for this particular patient's wellbeing and it is considered abnormal to have menstruation which needs to be reduced in frequency or abolished for a while. This is the condition which needed to be addressed.
 Well, I don't want to keep on placing what is relevant there from my many years of practice with the treatment of suppression of menstruation  with multitudes of patient and your stand seems to be strange and unacceptable in the  realm of clinical diagnosis and coding aspects where in both their theory fits well with mine. Since i have experience in both these arena, I came a long way only  to be  a jerk. It is high time I stop with my decision as the right one whether I am right or wrong on others view. Bye


----------



## mitchellde (Dec 16, 2010)

Sorry Preserene but I have to agree with the others on this.  The 626.8 is absolutely an incorrect choice in this case.  The main category heading which must be a part of the 626.8 code states this is a disorder or menstruation and other abnormal bleeding.  So when 626.8 states suppression of menstruation as a definiton it is meant supression as a disorder of the patient and not a normal patient that wishes to have a suppression of menstruation due to debilitation.  This code is also in the chapter for diseases and disorders of the genitourinary system, which this patient does not have.  Also the CDC creates ICD-9 codes not the AMA.  No one is questioning your experience or expertise.  It is just a misinterpretationof the codes.  We need to remember that this is the patient's dx and we must be absolutely correct and not read too much into what we are seeing either in the physician notes or in the ICD-9 book.  The CDC has put these codes in the book in a specific fashion for specific purposes.  While your rational is quite well thought out, the code simple does not work the way you would like it too.  The patient has no complain nor an identified genitourinary illness by the physician, and therefore we cannot use a code from this chapter.  I hope this will help everyone.


----------



## preserene (Dec 17, 2010)

"Disorders of Menstruation; 626.8 Others- MENSTRUATION: SUPPRESSION OF,"
 well for general population what you discuss very much applicable.I agree.
We do not have a definitive code for suppression of menstruation with the term "for normal menstruation; 

But scenario like this case:
It comes to my mind this Phrase" One man’s food is another man’s poison" at times. Here is a patient for whom the disorder of menstruation is the "normal-occuring cyclical menstruation".
Here is a patient who has made an encounter to the OBGYN specialist for only suppression of Menstruation. What is a normal functional phenomenon for an ordinary person, has become *dysfunctional/or disorder* for this lady and that is the whole lot of misery for her. What is 'NORMAL' for general population IS  phenomenally an abnormal condition at this juncture and the physician has to address to THIS ABNORMALITY IN HER TO WHAT IS SEEMINGLY NORMAL FOR HER and give treatment for her. That menstrual order is to be turned to what is normal for her deceased situation.
Though what you say is generally applicable and true to its sense for a general population, this case has to be individualized and  “her abnormality” of menstrual order is  to be managed with the treatment to correct to "her" normalcy, comfort and ease.
 So take the diagnosis part of "suppression of menstruation" which is to phenomenonly stop /restrict menstruation-irrespective of normal menstruation, abnormal menstruation or dysfunctional menstruation. When a client comes/encounters for that diagnosis, the existing menstruation in her is an abnormal,or dysfunctional condition FOR HER and we address that dysfunction to what is right to be HER FUNCTIONAL ,normalcy and treatment to make her comfortable and have a secured life.
On that perspectives, I place the encounter, what is deemed to be a disorder and dysfunctional "for her" into a management modality and  the code 636.8 as a valid one which is the main focus/reason for encounter(suppression of menstruation), though the V code which is to be first listed as per its merits and guidelines of ICD-9. 
It is only for a debate in the forum I take it; where else we have liberty to do?; not for who win or who loose. May be I am wrong. would I be stripped off my CPC or my professional postgraduation? I do not want to enter into arguement anymore.
Thanks for all your postings.


----------



## mitchellde (Dec 17, 2010)

What you are talking about is more a mental state of mind rather than a disease/disorder of the genitourinary system.  She is (or caregiver) choosing a lifestyle that maybe you think of abnormal given the general population but for her is perfectly rational and normal.  We cannot assign a disease code based on what we find personally reprehensible or abnormal given what we feel is normal.  As far as can you be stripped of credentials.. I do not know.  What I do know is you are suggesting assignment of a diagosis that has not been rendered by the physician nor that the patient has.  So you are in fact communicating a diagnosis that the patient does not have.  You are the coder and not the physician so we can never assign a diagnosis that is not rendered by the physician.  and we cannot assign our own definitions to the ICD-9 codes.  But assigning diagnosis incorrectly can have portential harm to the patient down the road.


----------



## preserene (Dec 17, 2010)

628.8 other -
DUB
Menstruation:
suppression of
This term "menstruation" usually is used for defining the normal menstrual cycle. 
Can't we construde it as applicable to suppression of menstruation, no matter what the cause is. the description goes for suppression of menstruation.
I am not happy with the statement  saying that my diagnosis is self given; this is the diagnosis given by the OBGYN. OBGYN do not have to give a primary diagnosis of CP or other medical condition as the primary diagnosis in this particular encounter for suppression of menstruation.
There are numerous other conditions for eg, endometriosis where in the physician finds medical necessity for inducing an artificial menopause, in other words suppression of Menstruation for a short while. There are variety of drugs being used for this.
Where do you place them for their encounter for Suppression of Menstruation for certain period.
There are much more conditions like that  where in the Suppression is not for contraception.
I feel that it is reasonable that this subcategory Code 626.8 or 626.9 could be meant for them too. Most of the abnormal uterine bleeding conditions have their own terminology and treatment modalities associated with it.
Suppression of menstruation is the general terminology in vogue by the Physicians  for creating cessation of period/creating an artificial menopause like condition 
and I feel that this  code description of Menstruation: Suppression of , could hold good for any condition which necessitates a medical necessity of creating a suppression of Menstruation irrespective-CP, endometriosis and many other conditions.
 Please do not make statement that I give a wrong diagnosis where in it was the diagnosis by the OBGYN "Suppression of Menstruation.
I do not have to be a physician to write my opinion , though one can be both at the same time!!!!! 
Cheerio Michellede , I do respect that you are an expert and with superb coding experience and knowledge


----------



## ohn0disaster (Dec 17, 2010)

You're not wrong, Brandi. Preserene doesn't like being told that someone doesn't agree with him. No matter how many years experience someone has, it does not mean that they are above misunderstanding. I, just for the heck of it, did some research on this subject. I went above that and took a print out of this entire thread to the OB/GYN that works with my office. And for YOUR kind information, he disagrees with you. He's the one that gave me a lot of the information that I posted above, which I then found plenty, just searching online, backing it up. I'm sure that, by now, debrowne has chosen what code they are going with, regardless of what it is. What I constantly find disturbing about posts in which preserene gets involved is the fact that he finds it so difficult to agree to disagree with someone and the attitude that radiates from his comments. There is, at the very least, a slight language issue. I can tell that he is an intelligent person but sometimes I feel that something is getting lost in translation. Plain and simple, you cannot force someone to agree with you. When someone posts a question, I'm sure they appreciate any helpful information that can be given to them. I just know that I'm tired of seeing the elitist attitude. Although your input is always welcomed, you're not always right.


----------



## mitchellde (Dec 17, 2010)

Menstruation:
suppression of
This term "menstruation" usually is used for defining the normal menstrual cycle.
Can't we construde it as applicable to suppression of menstruation,.....
NO we cannot construe it!  The code is for a disorder of menstruation and other abnormal bleeding..... This must be documented by the physician, and the meaning is clear in the ICD-9 book.  For an individual to express the desire to supress the menstral cycle is not abnormal nor is it a disorder.  There are birth control methods on the market currently that will supress mentruation for 4 months or more at a time, so are we to code these ladies as having a disorder as well??  If we are to apply your logic then the answer is yes, but this too would be wrong. The senario presented in the original post is no different than a young woman electing one of these methods of contraception.


----------

