Learn about perimenopause symptoms, diagnosis codes, and clinical documentation. Find information on irregular periods, hot flashes, night sweats, mood changes, sleep disturbances, and other common perimenopause indicators. Understand the medical coding and healthcare guidelines for documenting perimenopause in clinical settings. This resource provides valuable insights for healthcare professionals, including physicians, nurses, and medical coders, seeking accurate and comprehensive information on perimenopause diagnosis and management.
Also known as
Perimenopausal state
Encompasses the transition period surrounding menopause.
Ovarian dysfunction, unspecified
Covers irregular ovarian function common during perimenopause.
Retention of urine
Includes urinary symptoms, sometimes occurring during perimenopause.
Noninflammatory disorders of female genital tract
A broader category that may include some perimenopausal symptoms.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the patient experiencing irregular menses?
Yes
Other perimenopausal symptoms present?
No
Are other perimenopausal symptoms present?
When to use each related code
| Description |
|---|
| Perimenopause Symptoms |
| Early Menopause |
| Premature Ovarian Insufficiency |
Coding perimenopause symptoms with unspecified codes (e.g., N95.1) when more specific diagnoses are documented leads to inaccurate data and lower reimbursement.
Failing to capture related conditions like anxiety, depression, or sleep disorders alongside perimenopause impacts risk adjustment and quality reporting.
Insufficient clinical documentation to support the perimenopause diagnosis creates audit risks and potential claim denials. CDI can improve documentation.
Patient presents with symptoms consistent with perimenopause. The patient reports experiencing irregular periods, including changes in cycle length and flow, along with hot flashes, night sweats, and sleep disturbances. She also describes mood changes, including irritability and anxiety, as well as difficulty concentrating. Additionally, the patient reports vaginal dryness and decreased libido. These perimenopause symptoms have been ongoing for approximately six months and are impacting her quality of life. Menstrual history includes menarche at age 12 and previously regular cycles. Surgical history is unremarkable. Family history is positive for early menopause in her mother. Physical examination reveals normal vital signs. Pelvic examination is unremarkable. Differential diagnoses considered include thyroid dysfunction, anxiety disorders, and other hormonal imbalances. Laboratory evaluation includes thyroid stimulating hormone (TSH), follicle-stimulating hormone (FSH), and estradiol levels to assess hormonal status and rule out other conditions. Based on the patient's reported symptoms, clinical presentation, and preliminary evaluation, a diagnosis of perimenopause is made. The patient was educated on the physiological changes associated with perimenopause and provided information on management options, including lifestyle modifications such as regular exercise, stress management techniques, and dietary adjustments. Hormone therapy options, including estrogen and progestin therapy, were discussed, along with the risks and benefits of each treatment approach. The patient was encouraged to follow up for reevaluation and further management as needed. ICD-10 code N95.1 is documented for perimenopause.