Ob-Gyn Coding Alert

Whether patient is symptomatic or asymptomatic makes all the difference.

Menopause that occurs before the age of 40, whether natural or induced, is called "premature" menopause. A woman with premature menopause may deal with hot flashes, mood swings, and other symptoms that accompany menopause.

ICD-9-CM Code: Right now, you should report this condition with 256.31 (Premature menopause).

ICD-10-CM Codes: When your diagnosis coding system changes next year, you’ll report either E28.310 (Symptomatic premature menopause) or E28.319 (Asymptomatic premature menopause). Notice how these two options are dependent on whether the patient is symptomatic or asymptomatic.

Documentation: Underneath the entry for symptomatic premature menopause, you’ll see the following note: "Symptoms such as flushing, sleeplessness, headache, lack of concentration, associated with premature menopause." Therefore, the provider should document that the patient is experiencing these symptoms so that the coder can report E28.310.

Here’s how you’ll find the codes in your manual:

Menopause, menopausal (asymptomatic) (state) Z78.0

- premature E28.319

- - asymptomatic E28.319

- - - postirradiation E89.40

- - - postsurgical E89.40

- - symptomatic E28.310

- - - postirradiation E89.41

- - - postsurgical E89.41

Premature —see also condition - menopause E28.319

- - asymptomatic E28.319

- - symptomatic E28.310

Coder’s tips: Make certain you read your physician’s documentation to determine whether the patient has symptoms of premature menopause (E28.310) or is not experiencing any symptoms with her premature menopause (E28.319).