Find comprehensive information on documenting a history of Polycystic Ovary Syndrome (PCOS) for accurate medical coding and billing. This resource covers PCOS diagnosis criteria, including clinical findings, laboratory results, and relevant ICD-10 codes (E28.2). Learn about proper medical record documentation for PCOS, including patient history, symptoms like hirsutism, oligomenorrhea, and infertility, and management strategies. Improve your healthcare documentation practices and ensure accurate representation of PCOS diagnosis for optimal clinical care and reimbursement.
Also known as
Polycystic ovary syndrome
Hormonal disorder causing enlarged ovaries with small cysts.
Female infertility
Infertility related to female reproductive organs.
Other ovarian dysfunction
Disorders of ovarian function not elsewhere classified.
Hyperlipidemia
Elevated levels of lipids in the blood, a common PCOS comorbidity.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the PCOS currently active?
Yes
Code E28.2 Polycystic ovary syndrome
No
Is there any other current manifestation?
When to use each related code
| Description |
|---|
| Polycystic Ovary Syndrome (PCOS) |
| Hypothyroidism |
| Non-Classic Congenital Adrenal Hyperplasia |
Coding PCOS without specifying type (e.g., classic, non-classic) when documented leads to inaccurate severity reflection and potential payment errors.
Overlooking associated diagnoses like hirsutism, infertility, or insulin resistance impacts risk adjustment and care planning.
Incorrectly coding suspected or ruled-out PCOS as a confirmed history can inflate prevalence data and trigger unnecessary audits.
Patient presents with a history of polycystic ovary syndrome (PCOS), diagnosed in [Month, Year] via [Diagnostic criteria e.g., Rotterdam criteria, NIH criteria] based on [Symptoms present at diagnosis e.g., oligomenorrhea, hyperandrogenism, polycystic ovaries on ultrasound]. Current symptoms include [List current symptoms e.g., irregular periods, hirsutism, acne, weight gain, difficulty losing weight, mood changes, infertility, pelvic pain]. Patient reports cycle length of [Number] days with menses lasting [Number] days. She denies galactorrhea. Family history is significant for [Family history related to PCOS or related conditions e.g., diabetes, cardiovascular disease]. Physical examination reveals [Physical exam findings related to PCOS e.g., BMI of [Number], acne, hirsutism, acanthosis nigricans]. Previous treatments for PCOS include [List previous treatments e.g., oral contraceptives, metformin, spironolactone, lifestyle modifications]. Assessment: History of PCOS, currently presenting with [Summarize current symptomatic presentation]. Plan: Discussed the pathophysiology of PCOS, long-term health risks including insulin resistance, type 2 diabetes, cardiovascular disease, and endometrial hyperplasia. Treatment options including lifestyle modifications (diet, exercise), pharmacologic management for menstrual regulation (oral contraceptives, progestins), and hirsutism management (spironolactone) were reviewed. Patient was counseled on the importance of regular follow-up for monitoring and management of PCOS symptoms and associated health risks. Referral to [Specialty if applicable, e.g., endocrinology, reproductive endocrinology, registered dietitian] was discussed. Follow-up scheduled in [Timeframe].