ICD-10 Coding for Abnormal Vaginal Bleeding(N93.9, N92.4, D25.0)
Complete ICD-10-CM coding and documentation guide for Abnormal Vaginal Bleeding. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Abnormal Vaginal Bleeding
N92-N93Primary Range
Excessive, frequent and irregular menstruation
This range includes codes for various types of abnormal uterine bleeding, including excessive and irregular menstruation.
Leiomyoma of uterus
This range is relevant for cases where fibroids are the underlying cause of abnormal bleeding.
Malignant neoplasm of corpus uteri
This range is used when endometrial cancer is the cause of abnormal bleeding.
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 bleeding is not identified after a thorough evaluation. |
|
| N92.4 | Excessive bleeding in the premenopausal period | Use for excessive bleeding in premenopausal women without identified structural causes. |
|
| D25.0 | Submucous leiomyoma of uterus | Use when fibroids are confirmed as the cause of bleeding. |
|
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 vaginal bleeding
Essential facts and insights about Abnormal Vaginal Bleeding
Primary ICD-10-CM Codes for abnormal vaginal bleeding
Decision Criteria
clinical Criteria
- No specific cause identified after evaluation
Applicable To
- Unspecified abnormal uterine bleeding
Clinical Validation Requirements
- No identifiable cause after workup
- Negative pregnancy test
Code-Specific Risks
- Risk of overuse when specific causes are not documented.
Coding Notes
- Ensure thorough documentation to justify the use of an unspecified code.
N92.4 - Excessive bleeding in the premenopausal period
Use for excessive bleeding in premenopausal women without identified structural causes.
Applicable To
- Premenopausal menorrhagia
Excludes
- Postmenopausal bleeding (N95.0)
Clinical Validation Requirements
- Hgb <10 g/dL
- Menstrual history indicating excessive bleeding
Coding Notes
Document menstrual patterns and any associated symptoms.
D25.0 - Submucous leiomyoma of uterus
Use when fibroids are confirmed as the cause of bleeding.
Applicable To
- Fibroid causing abnormal bleeding
Excludes
- Malignant neoplasm of uterus (C54-C55)
Clinical Validation Requirements
- TVUS showing fibroid >3cm
- Documented menorrhagia
Coding Notes
Document imaging findings and symptoms clearly.
Differential 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 Vaginal 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: Increases risk of coding errors., Financial: Potential for claim denials.
Mitigation Strategy
Always include menopausal status in patient history., Use checklists to ensure comprehensive documentation.
Impact
Reimbursement: May result in lower reimbursement rates., Compliance: Increases risk of audit failures., Data Quality: Reduces accuracy of clinical data.
Mitigation Strategy
Always document and code the specific cause of bleeding when known.
Impact
High risk of audit if unspecified codes are used without proper documentation.
Mitigation Strategy
Ensure thorough documentation of diagnostic workup and findings.
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 Vaginal Bleeding, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Abnormal Vaginal Bleeding
Use these documentation templates to ensure complete and accurate documentation for Abnormal Vaginal Bleeding. These templates include all required elements for proper coding and billing.
Premenopausal excessive bleeding
Specialty: GynecologyRequired Elements
- Menstrual history
- Pelvic exam findings
- Imaging results
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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