Find comprehensive information on Heavy Menstrual Bleeding diagnosis, including clinical documentation tips, ICD-10 codes (N92.0, N92.1), medical coding guidelines, and healthcare best practices. Learn about menorrhagia, abnormal uterine bleeding (AUB), and related terms for accurate diagnosis and billing. This resource offers valuable insights for physicians, nurses, and medical coders seeking accurate and efficient documentation for Heavy Menstrual Bleeding.
Also known as
Excessive and frequent menstruation
Covers various types of heavy menstrual bleeding.
Other abnormal uterine bleeding
Includes unspecified abnormal bleeding, not elsewhere classified.
Unspecific hematuria
May be relevant if blood in urine is associated with menses.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the HMB due to an underlying medical condition?
Yes
Is it due to a coagulation disorder?
No
Is it AUB-HMB (DUB)?
When to use each related code
| Description |
|---|
| Heavy prolonged periods |
| Heavy irregular periods |
| Short frequent periods |
Using unspecified ICD-10 codes (e.g., N92.0) when more specific diagnoses like menorrhagia (N92.1) or metrorrhagia (N92.2) are applicable, leading to inaccurate reporting.
Insufficient documentation to support HMB diagnosis, impacting coding accuracy and potential denials for procedures related to HMB management like endometrial ablation.
Failure to document and code associated iron deficiency anemia (D50.x) when present with HMB, impacting severity and resource utilization reporting.
Patient presents with complaints consistent with heavy menstrual bleeding (menorrhagia). She reports prolonged menstrual periods lasting greater than seven days (hypermenorrhea) and excessive menstrual blood loss requiring frequent pad or tampon changes (e.g., more than one per hour). The patient describes soaking through clothing or bedding, passing large blood clots (menstrual clots), and experiencing symptoms of anemia such as fatigue, weakness, shortness of breath (dyspnea), and pallor. Menstrual cycle length and regularity were explored, including intermenstrual bleeding and metrorrhagia. Differential diagnoses considered include uterine fibroids, endometrial polyps, adenomyosis, endometrial hyperplasia, coagulopathies, and hormonal imbalances. A pelvic exam was performed to assess uterine size, shape, and tenderness. Laboratory tests ordered include a complete blood count (CBC) to evaluate for anemia, coagulation studies (PT/INR, PTT) to assess for bleeding disorders, and thyroid function tests (TSH) to rule out thyroid dysfunction. Depending on the patient's age and risk factors, endometrial biopsy or transvaginal ultrasound may be indicated to evaluate the endometrium. Initial management may include medical therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management and hormonal treatments such as combined oral contraceptives, progestin-only pills, or a levonorgestrel intrauterine device (IUD) to control bleeding. Patient education was provided regarding menstrual hygiene, iron supplementation for anemia, and the potential benefits and risks of various treatment options. Follow-up appointment scheduled to reassess symptoms and discuss further management if needed. ICD-10 code N92.0 (Heavy menstrual bleeding) is documented for billing purposes.