Ob-Gyn Coding Alert

Here’s how to tell the difference between osteoporosis and osteopenia.

Spare yourself denial hot flashes by taking this three-part postmenopausal abnormality scenario challenge.

Background: Menopause is the normal physiologic cessation of menstruation that occurs as a woman ages because the ovaries stop producing estrogen and the reproductive system gradually shuts down. This process, which has an average age of onset at 50.5 years, usually takes approximately one year to complete, but it may last anywhere from six months to more than five years.

Your ob-gyn may see a perimenopausal patient for any number of conditions, including vaginal dryness, erratic or scanty menstrual cycles, or vaginal atrophy. Consequently, you should be aware of the conditions that can occur during this phase of a woman’s life.

Fill In These Blanks Using Your ICD-10 Book

Question 1: Your ob-gyn sees a postmenopausal patient with an inflamed vagina because the tissues are thinning and shrinking. The ob-gyn notes decreased vaginal wall lubrication. This patient is experiencing vaginal soreness and itching, painful intercourse, and bleeding after intercourse. The ob-gyn diagnoses the patient with _________, and you should report this with _________.

Question 2: Your ob-gyn sees a postmenopausal patient with unusual or abnormal vaginal bleeding. You should report _________.

Question 3: Because _________ occurs more frequently in postmenopausal women, your ob-gyn assesses and treats this bone disease. You should report it with _________.

3 Answers Probe Postmenopausal Conditions

Answer 1: The ob-gyn diagnoses the patient with atrophic vaginitis, and you should report this with N95.2 (Postmenopausal atrophic vaginitis). Generally, the lack of estrogen during and following menopause causes this condition.

Additional causes for atrophic vaginitis include decreased estrogen due to decreased ovarian function after radiation or chemotherapy, oophorectomy, postpartum changes and immune disorders.

The ob-gyn will diagnose this condition via a pelvic exam, which will reveal thin, pale vaginal walls, but he may order lab tests to confirm menopause and rule out other conditions that might mimic it. According to Melanie Witt, RN, MA, an ob-gyn coding expert based in Guadalupita, N.M., for potentially menopausal women who may have premature ovarian failure or who are being evaluated for risk of other health problems, the ob-gyn may order one or more of the following tests:

• follicle-stimulating hormone (FSH): to learn whether she is approaching or has gone through menopause estradiol: to measure ovarian production of estrogen and to evaluate whether the menstrual cycle is normal
• thyroid function testing (free T4 and TSH): to test the function of the thyroid gland, which can slow with age, affect menstruation, and cause some symptoms similar to those seen with menopause.

For this condition, your ob-gyn may prescribe topical estrogen creams or tablets for vaginal use or transdermal estrogen. Writing prescriptions is part of the office visit (99201-99215, Office or other outpatient visit ...), Witt says.

Link This Condition to Endometrial Biopsies

Answer 2: Your ob-gyn sees a postmenopausal patient with unusual or abnormal vaginal bleeding. You should report N95.0 (Postmenopausal bleeding). Endometrial atrophy or endometrial or vaginal cancer can cause postmenopausal bleeding.

Keep in mind: The patient may also be on hormone replacement therapy which can cause this bleeding, have atrophic vaginitis, have recently lost weight (which affects the body by releasing stored estrogen), or have fibroids or polyps. For this condition, the ob-gyn may frequently perform biopsies of the endometrium (58100-+58110 or 58558, Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C), D&C (58120, Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical)), or hysteroscopy (58555, Hysteroscopy, diagnostic (separate procedure)), Witt says.

Weigh Osteoporosis, Osteopenia Differences

Answer 3: Trick question.

One option is osteoporosis, (M81.0, Age-related osteoporosis without current pathological fracture). This condition is essentially a bone disease caused by dropping estrogen levels in postmenopausal women. Osteoporosis, or porous bone, is a disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased risk of fractures of the hip, spine, and wrist.

Another option is osteopenia, in which bone mineral density is lower than normal. Your ICD-10 options are M85.8- (Other specified disorders of bone density and structure). The correct code is determined by the location (i.e., shoulder, hand, upper arm, forearm, thigh, lower leg, ankle/foot, or other). While osteopenia can be a risk factor or precursor for developing osteoporosis, all patients who have osteopenia do not develop osteroporosis.

For osteopenia, the ob-gyn may recommend calcium supplements and weight bearing exercises.

Treatment: Your ob-gyn most likely will order a dual energy x-ray absorptiometry (DEXA, 77080-77081, 77085), which measures bone density, to diagnose the condition Depending on the results, he will prescribe bisphosphonate, vitamin D, and calcium supplements.

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