Understand abnormal bleeding, also known as abnormal uterine bleeding, menorrhagia, or irregular menstruation. This guide covers key aspects of diagnosis, clinical documentation, and medical coding for healthcare professionals. Learn about the proper terminology and coding practices associated with abnormal bleeding for accurate medical records and effective patient care.
Also known as
Excessive, frequent, and irregular menstruation
Covers various abnormal menstrual bleeding patterns.
Other abnormal uterine bleeding
Includes unspecified abnormal uterine bleeding.
Unspecific hematuria
Relates to blood in urine, which can sometimes accompany bleeding disorders.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the abnormal bleeding related to pregnancy, childbirth, or the puerperium?
Yes
Refer to pregnancy-related bleeding codes (e.g., O00-O9A).
No
Is there a known underlying cause?
When to use each related code
| Description |
|---|
| Heavy or prolonged menstrual bleeding. |
| Bleeding between periods or after menopause. |
| Infrequent, irregular, or absent periods. |
Coding AUB/menorrhagia without specifying cause (e.g., fibroids, hormonal imbalance) leads to inaccurate severity and reimbursement.
Lack of sufficient clinical documentation to support abnormal uterine bleeding diagnosis may trigger payer denials and compliance issues.
Incorrectly coding menorrhagia (heavy bleeding) as metrorrhagia (irregular bleeding) impacts data accuracy and treatment planning.
Q: What are the most effective diagnostic approaches for differentiating between causes of abnormal uterine bleeding in perimenopausal women?
A: Diagnosing the cause of abnormal uterine bleeding (AUB), particularly in perimenopausal women, requires a systematic approach to differentiate between benign and malignant etiologies. Initial assessment should include a detailed medical history encompassing menstrual cycle characteristics, obstetric history, medication use (including anticoagulants and hormonal therapies), and symptoms suggestive of thyroid disorders or bleeding diatheses. Physical examination should focus on pelvic anatomy and signs of systemic illness. Transvaginal ultrasound is crucial for evaluating endometrial thickness and identifying structural abnormalities like fibroids or polyps. Consider endometrial biopsy, especially for women over 45 or with risk factors for endometrial hyperplasia or cancer, when endometrial thickness exceeds 4mm or if bleeding persists despite treatment. Sonohysterography or hysteroscopy may be helpful to further evaluate intrauterine pathology. Laboratory tests like complete blood count, thyroid function tests, and coagulation studies can be informative based on the patient's presentation. Explore how these diagnostic steps can be incorporated into a comprehensive evaluation algorithm for AUB in perimenopausal patients.
Q: How do current clinical guidelines recommend managing abnormal uterine bleeding due to ovulatory dysfunction (AUB-O) in adolescents?
A: Managing abnormal uterine bleeding due to ovulatory dysfunction (AUB-O) in adolescents requires a patient-centered approach that considers the individual's age, severity of symptoms, and treatment goals. For adolescents with mild AUB-O and without significant anemia, reassurance and observation can be appropriate, particularly if the bleeding is self-limited. Combined oral contraceptives (COCs) are often the first-line pharmacologic therapy for managing AUB-O in adolescents who desire contraception or require more active bleeding control. Alternative hormonal options include the progestin-only pill, depot medroxyprogesterone acetate injection, or the levonorgestrel-releasing intrauterine system, each with its own benefits and risks. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be considered for symptom management, particularly for adolescents with heavy menstrual bleeding. Iron supplementation should be addressed if anemia is present. Consider implementing a shared decision-making process with the adolescent and their family to tailor the management plan to their specific needs and preferences. Learn more about the potential benefits and risks of each treatment option for adolescent AUB-O.
Patient presents with complaints consistent with abnormal uterine bleeding. The patient describes [frequency, duration, and flow of bleeding; e.g., prolonged menses lasting greater than seven days, heavy menstrual bleeding with clots, or frequent bleeding occurring less than 21 days apart]. Menstrual history includes menarche at age [age], cycle length typically [number] days, and flow usually described as [light, normal, or heavy]. The patient reports [presence or absence of associated symptoms; e.g., pelvic pain, cramping, fatigue, dizziness, or shortness of breath]. Relevant medical history includes [list relevant medical conditions such as fibroids, endometriosis, PCOS, bleeding disorders, or thyroid disorders]. Current medications include [list current medications including hormonal contraceptives, anticoagulants, or other relevant medications]. Physical examination reveals [relevant findings such as uterine size, tenderness, or adnexal masses]. Differential diagnosis includes menorrhagia, metrorrhagia, menometrorrhagia, dysfunctional uterine bleeding, and potential underlying structural or systemic causes. Assessment suggests abnormal uterine bleeding, likely secondary to [suspected cause if identifiable]. Plan includes [ordered laboratory tests such as CBC, coagulation studies, thyroid function tests, and hormonal panels; imaging studies such as pelvic ultrasound or transvaginal ultrasound; and planned treatment such as hormonal therapy, nonsteroidal anti-inflammatory drugs NSAIDs, or surgical interventions]. Patient education provided regarding menstrual hygiene, management of symptoms, and potential complications. Follow-up scheduled in [timeframe] to reassess symptoms and discuss management plan. ICD-10 code [appropriate ICD-10 code such as N92.0, N92.1, or other appropriate code] is considered.