ICD-10 Coding for Secondary Amenorrhea(N91.1)
Complete ICD-10-CM coding and documentation guide for Secondary Amenorrhea. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Secondary Amenorrhea
N91-N92Primary Range
Other abnormal uterine and vaginal bleeding
This range includes codes for various menstrual disorders, including secondary amenorrhea.
Key Information: ICD-10 code for secondary amenorrhea
Essential facts and insights about Secondary Amenorrhea
Primary ICD-10-CM Code for secondary amenorrhea
Decision Criteria
clinical Criteria
- Absence of menstruation for at least 3 months in regular cycles or 6 months in irregular cycles
documentation Criteria
- Exclusion of pregnancy, menopause, and breastfeeding
Applicable To
- Absence of menstruation for 3 months in women with previously regular cycles
- Absence of menstruation for 6 months in women with previously irregular cycles
Clinical Validation Requirements
- Documented absence of menstruation for the specified duration
- Exclusion of pregnancy, menopause, and breastfeeding
- Relevant lab tests such as FSH, TSH, and prolactin levels
Code-Specific Risks
- Misclassification if duration is not specified
- Excludes1 note violations if ovarian dysfunction is not separately coded
Coding Notes
- Ensure documentation specifies the duration of amenorrhea and excludes other causes.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Secondary Amenorrhea to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N91.1.
Impact
Clinical: Misdiagnosis and inappropriate treatment plans., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials or audits.
Mitigation Strategy
Always perform and document a pregnancy test, Review patient history for potential causes
Impact
Reimbursement: May lead to denied claims due to lack of specificity., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data affecting patient care.
Mitigation Strategy
Ensure the duration of amenorrhea is documented to use N91.1 instead of N91.2.
Impact
Inadequate documentation of the duration can lead to incorrect coding.
Mitigation Strategy
Ensure all patient records specify the exact duration of amenorrhea.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Secondary Amenorrhea, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Secondary Amenorrhea
Use these documentation templates to ensure complete and accurate documentation for Secondary Amenorrhea. These templates include all required elements for proper coding and billing.
Evaluation of secondary amenorrhea
Specialty: GynecologyRequired Elements
- Menstrual history
- BMI
- Lab results (FSH, TSH, prolactin)
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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