ICD-10 Coding for Abnormal Uterine Bleeding(N93.9, D25.0)
Complete ICD-10-CM coding and documentation guide for Abnormal Uterine Bleeding. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Abnormal Uterine Bleeding
N92-N93Primary Range
Excessive, frequent and irregular menstruation
This range includes codes for various types of abnormal uterine bleeding, including unspecified and specific causes.
Leiomyoma of uterus
This range is relevant when AUB is due to fibroids, which are a common structural cause.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N93.9 | Unspecified abnormal uterine and vaginal bleeding | Use when the cause of AUB is not specified or determined. |
|
| D25.0 | Submucous leiomyoma of uterus | Use when AUB is due to fibroids confirmed by imaging. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for abnormal uterine bleeding
Essential facts and insights about Abnormal Uterine Bleeding
Primary ICD-10-CM Codes for abnormal uterine bleeding
Decision Criteria
documentation Criteria
- Document lack of identifiable cause after appropriate testing.
Clinical Validation Requirements
- Endometrial biopsy negative for malignancy
- Ultrasound ruling out structural causes
Code-Specific Risks
- Risk of under-documentation if cause is known but not recorded.
Coding Notes
- Ensure documentation specifies 'unspecified' if no cause is determined.
D25.0 - Submucous leiomyoma of uterus
Use when AUB is due to fibroids confirmed by imaging.
Applicable To
- Fibroids causing AUB
Excludes
- Malignant neoplasm of uterus (C54.1)
Clinical Validation Requirements
- Ultrasound confirming fibroid presence and size
Coding Notes
Ensure fibroid documentation includes size and location.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Iron deficiency anemia secondary to blood loss (chronic)
D50.0Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Abnormal Uterine Bleeding to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N93.9.
Impact
Clinical: May lead to inappropriate treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims.
Mitigation Strategy
Use specific terms like 'menorrhagia' or 'metrorrhagia'., Document diagnostic findings.
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Always document and code the specific cause if known.
Impact
High risk of audit if unspecified codes are overused.
Mitigation Strategy
Document all diagnostic findings and specify causes.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Abnormal Uterine Bleeding, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Abnormal Uterine Bleeding
Use these documentation templates to ensure complete and accurate documentation for Abnormal Uterine Bleeding. These templates include all required elements for proper coding and billing.
AUB due to fibroids
Specialty: GynecologyRequired Elements
- Patient history
- Ultrasound findings
- Menstrual history
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Abnormal Uterine Bleeding? Ask your questions below.