October 25, 2010

Coding for Menopause
For The Record
Vol. 22 No. 19 P. 28

Menopause is the confirmed end of menstruation and fertility when a woman has not experienced her menses for 12 consecutive months. It is related to age and reduced estrogen levels and normally occurs when a woman is in her early 50s. Although menopause is not a medical illness, the hormonal changes can cause physical and emotional symptoms.

Menopause may occur naturally due to a decrease in the reproductive hormones estrogen and progesterone, which regulate menstruation. It may also be the result of a hysterectomy or bilateral oophorectomy. When a woman’s menstruations stop immediately with no transition phase, she will more than likely experience the physical signs and symptoms of menopause. Menopause may also be induced due to chemotherapy or radiation therapy.

Signs and symptoms of menopause may occur before the condition is officially diagnosed. Common signs and symptoms include irregular menstrual periods, decreased fertility, vaginal dryness, hot flashes, sleep disturbances, mood swings, low libido, increased abdominal fat, thinning hair, and loss of breast fullness.

Perimenopause is diagnosed when someone experiences the signs and symptoms of menopause but is still menstruating. This stage may last several years. Although a perimenopausal patient may still be able to get pregnant, it is highly unlikely.

Postmenopause are the years that follow the 12 months after the last menstruation cycle.

Menopausal disorders are classified to ICD-9-CM category 627. Codes that are related to premenopausal or menopausal disorders include the following:

• 627.0 — Premenopausal menorrhagia, which includes premenopausal bleeding/hemorrhage and menopausal bleeding/hemorrhage/menorrhagia; and

• 627.2 — Symptomatic menopausal or female climacteric states and may include these symptoms: crisis, flushing, headache, insomnia/sleeplessness, lack of focus/concentration, neurosis, and psychoneurosis.

Codes associated with postmenopausal disorder include the following:

• 627.1 — Postmenopausal bleeding/hemorrhage;

• 627.3 — Postmenopausal atrophic vaginitis;

• 627.8 — Other specified menopausal and postmenopausal disorders, which includes postmenopausal endometrium; and

• 627.9 — Unspecified menopausal and postmenopausal disorder.

These codes are used for natural or age-related menopause. Symptoms related to artificial or induced menopause are classified to code 627.4, Symptomatic states associated with artificial menopause.

Premature menopause (256.31), also documented as early menopause or premature ovarian failure, is the natural loss of ovarian function in women younger than the age of 40 (AHA Coding Clinic for ICD-9-CM, 2001, fourth quarter, page 41). If symptoms associated with natural menopause are also present, then assign code 627.2 as a secondary diagnosis with code 256.31. Premature menopause related to postirradiation or postsurgical is classified to code 256.2. Also assign code 627.4 if symptoms related to the artificial menopause are present.

The asymptomatic status of age-related or natural menopause is assigned to code V49.81. This code is used if no symptoms related to menopause or postmenopause are present. This code should not be used for patients who have experienced surgical or premature menopause (AHA Coding Clinic for ICD-9-CM, 2000, fourth quarter, pages 51-52).

The following are conditions that may occur in a postmenopausal patient: cardiovascular disease, osteoporosis, urinary incontinence, and weight gain.

Menopause is diagnosed mainly on the physical signs and symptoms, a woman’s medical history, and a review of her menstrual history. The physician may order blood tests to check the level of follicle-stimulating hormone (FSH) and estrogen. During menopause, the FSH level will increase and the estrogen level will decrease. The physician may also want to eliminate other possibilities, such as hypothyroidism, causing the signs and symptoms.

Only the signs and symptoms, and possibly common complications, of menopause are directly treated. Common treatment options include hormone therapy, antidepressants, gabapentin (Neurontin), clonidine (Catapres), bisphosphonates, selective estrogen receptor modulators, and vaginal estrogen.

Coding and sequencing for menopause are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.