Find comprehensive information on Polycystic Ovary Syndrome (PCOS) diagnosis, including clinical documentation, medical coding, ICD-10 codes (E28.2), and SNOMED CT concepts. Learn about PCOS symptoms, diagnostic criteria, laboratory tests, and treatment options. This resource provides valuable insights for healthcare professionals, medical coders, and clinicians seeking accurate and up-to-date information on PCOS management and documentation in electronic health records (EHR). Explore resources related to hirsutism, amenorrhea, infertility, and metabolic syndrome associated with PCOS.
Also known as
Polycystic ovary syndrome
Hormonal disorder causing enlarged ovaries with small cysts.
Other ovarian dysfunction
Ovarian disorders not elsewhere classified, potentially related to PCOS.
Female infertility
Infertility related to female reproductive organs, sometimes a consequence of PCOS.
Other endocrine disorders
General endocrine issues that may overlap with PCOS symptoms or complications.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the diagnosis Polycystic Ovary Syndrome (PCOS)?
Yes
Is the PCOS associated with infertility?
No
Do not code E28.2. Code the presenting condition.
When to use each related code
Description |
---|
Hormonal disorder causing irregular periods, excess hair growth, acne. |
Absent or infrequent menstruation unrelated to pregnancy or menopause. |
Excessive male pattern hair growth in women. |
Incorrect sequencing of PCOS diagnosis with manifestations like infertility or hirsutism can impact reimbursement and data accuracy. Medical coding and CDI should ensure proper code hierarchy.
Using unspecified PCOS codes (e.g., E28.2) when more specific documentation is available leads to lower reimbursement and inaccurate reporting. CDI can clarify documentation for specific type.
Failing to code associated PCOS manifestations like menstrual irregularities, acne, or obesity undercodes severity and complexity. CDI should query physicians for complete documentation of all symptoms.
Patient presents with symptoms suggestive of Polycystic Ovary Syndrome (PCOS), including irregular periods (oligomenorrhea), hirsutism (excess hair growth), and acne. She reports a history of menstrual irregularities since menarche, with cycles ranging from 35-60 days. Patient denies any current use of hormonal contraception. Physical examination reveals mild hirsutism on the face and chest, along with several comedones on the face and back. Abdominal examination is unremarkable. Pelvic ultrasound findings indicate polycystic ovaries, meeting the Rotterdam criteria for PCOS diagnosis. Laboratory evaluation reveals elevated androgen levels, specifically testosterone and free testosterone, with normal DHEA-S. Fasting glucose and lipid panel are within normal limits. Differential diagnoses considered include idiopathic hirsutism, congenital adrenal hyperplasia, and androgen-secreting tumors, but based on clinical presentation and laboratory results, PCOS is the most likely diagnosis. The patient was counseled on lifestyle modifications, including diet and exercise, for weight management and improvement of insulin sensitivity. She was also informed about the potential long-term health risks associated with PCOS, such as type 2 diabetes and cardiovascular disease. Treatment options, including metformin for insulin resistance and combined oral contraceptives for menstrual regulation and hirsutism management, were discussed. The patient will be scheduled for follow-up in three months to monitor treatment progress and address any further concerns. ICD-10 code E28.2 (Polycystic ovarian syndrome) is assigned.