March 2, 2009

Coding for Polycystic Ovary Syndrome
For The Record
Vol. 21 No. 5 P. 27

Polycystic ovary syndrome (PCOS) results from a disruption in the monthly reproductive cycle and occurs when levels of certain hormones are abnormal or out of balance. PCOS is mainly characterized by irregular menstrual periods, excessive hair growth, and obesity.

Although there is no known cause, the condition may be related to increased insulin production in the body. With PCOS, the body produces an excess of androgens, which are the male sex hormones, and the ratio of luteinizing hormone (LH) and follicle-stimulating hormone is abnormally high. An excess of androgens prevents ovulation, which causes excess hair growth and possibly infertility. Due to the androgens, some eggs develop into cysts, which build up in the ovaries and may become enlarged.

PCOS, which was once called Stein-Leventhal syndrome, is assigned to ICD-9-CM code 256.4. The term isosexual virilization is also included under code 256.4.

Symptoms
The following are common PCOS symptoms:

• irregular or missed periods or no menstruation;

• hirsutism (abnormal hairiness) on the face, chest, lower abdomen, back, upper arms, or upper legs;

• alopecia (thinning of hair);

• acne;

• enlarged ovaries with multiple cysts;

• infertility;

• obesity, weight gain, or difficulty maintaining a normal weight;

• type 2 diabetes; and

• acanthosis nigricans (darkened, thickened skin around the neck, armpits, or breasts).

High blood pressure or cholesterol levels, elevated levels of C-reactive protein, nonalcoholic steatohepatitis, or sleep apnea may also occur.

Diagnosis
PCOS is diagnosed by excluding other conditions first. The physician will rule out other possible disorders that may also cause the signs and symptoms the patient is experiencing. The physician may perform the following to help diagnose the condition:

• complete physical exam, including a pelvic exam;

• blood tests to measure levels of hormones, fasting glucose, cholesterol, and triglycerides; or

• ultrasound to check the ovaries and the thickness of the uterine lining. The ultrasound can detect ovarian cysts, which are not harmful but may lead to hormone imbalances.

Treatment
PCOS is a lifelong condition that may begin in the teen years. Treatment will depend on the symptoms present. The obesity and/or weight gain is important to treat with regular exercise and a proper heart-healthy diet, as the physician will want to prevent heart disease.

The physician may prescribe medications to manage other symptoms. To regulate the menstrual cycle, the physician may use the following medications:

• oral contraceptives;

• progesterone, which regulates the menstrual cycle and offers protection against endometrial cancer; or

• metformin (Glucophage, Glucophage XR), which treats type 2 diabetes, improves ovulation, and may reduce androgen levels. Metformin may not protect against endometrial cancer.

To reduce excessive hair growth, the physician may prescribe the following medications:

• spironolactone (Aldactone), which blocks the effects of androgen and reduces new androgen production; or

• eflornithine (Vaniqa), a topical cream that slows facial hair growth in women.

To assist with fertility, the following medications may be prescribed:

• clomiphene (Clomid, Serophene), which may be used in combination with metformin; or

• gonadotropin injections.

Occasionally, surgery is recommended to help with fertility. The physician may perform an outpatient surgery called laparoscopic ovarian drilling (65.99). The procedure will burn holes in enlarged follicles on the surface of the ovaries to hopefully reduce levels of LH and androgen hormones.

Coding and sequencing for polycystic ovary syndrome 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 4,000 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.