Documenting and coding polycystic ovary syndrome (pcos)
Documenting and Coding
PCOS is a common condition
affecting a woman’s hormone
levels. The article details the
symptoms, treatments and the
ICD-10 codes for documenting
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PCOS is a multifaceted hormonal disorder common among women of reproductive age.
Also known as or Stein-Leventhal syndrome, this condition affects a women’s hormone
levels. Women suffering from this endocrine system disorder produce higher-than-normal
amounts of male hormones (androgen). This hormone imbalance causes them to have
infrequent or prolonged menstrual periods, which makes it harder for them to get
pregnant. The ovaries are typically enlarged and may contain multiple small cyst-like
structures (immature ovarian follicles) that fail to regularly release eggs. If left untreated,
this hormone imbalance can affect everything - from a woman’s menstrual cycle and to her
appearance, ability to have children and her overall health. Obstetrics and Gynecology
medical billing and coding can be complex. Gynecologists/ endocrinologists who provide
treatment for this hormonal disorder should ensure that the medical coding for this
condition is properly done on the medical claims. Physicians should have essential medical
billing and coding know-how and use the correct diagnosis and procedure codes to
ensure correct and timely claim filing and reimbursement.
PCOS is one of the most critical and under-diagnosed conditions affecting women’s health.
Reports suggest that about 5 - 20 percent of women of childbearing age in the United States
suffer from this condition. The exact cause of PCOS is not known. The high levels of male
hormones may prevent the ovaries from producing hormones and making eggs normally.
In addition, certain other factors that may play an active role include - genetics, excess
insulin, low-grade inflammation and high levels of androgen.
Know the Symptoms
In most cases, the initial signs and symptoms of PCOS develop around the time of the first
menstrual period during puberty. However, in some rare cases, it may develop later (for
instance in response to substantial weight gain or having trouble getting pregnant). The
signs and symptoms of this condition may vary and some of the common symptoms include
Acne, oily skin, and dandruff
Excessive hair growth (on face and body - including on their back, belly, and chest)
Darkening of the skin
Excess androgen levels
High stress levels
High blood pressure
Some other complications associated with this hormonal disorder include - Gestational
diabetes or pregnancy-induced high blood pressure, miscarriage or premature birth, Type
2 diabetes or pre-diabetes, endometrial cancer, nonalcoholic steatohepatitis (a severe liver
inflammation caused by fat accumulation in the liver) and other related metabolic
Diagnosis Tests and Treatment Methods
There is no single test that can definitively diagnose the presence of PCOS. However, the
initial diagnosis will begin with a detailed discussion with the physician, wherein he/she
will evaluate in detail your previous medical history and ask specific questions relating to
your menstrual periods and weight changes. Physicians will check for signs of excess hair
growth, insulin resistance and acne. A detailed physical examination that includes - a pelvic
exam and blood tests (to measure hormone, cholesterol and glucose levels) will also be
conducted. In addition, an ultrasound may be used to look at the uterus and ovaries.
PCOS treatment may initially focus on managing individual problems such as abnormal
menstrual periods, obesity, infertility, hirsutism or acne. Treatment modality may include a
combination of medications along with serious lifestyle changes. In order to regulate your
menstrual cycle, physicians may recommend medications that include - birth control pills,
and progestin therapy. To help women ovulate physicians may prescribe hormone
medications like - Clomiphene (Clomid), Letrozole (Femara), Gonadotropins, Metformin
(Glucophage, Fortamet) and Spironolactone (Aldactone).
Endocrinology medical billing and coding involves using the specific ICD-10 diagnosis
codes for reporting various conditions such as – polycystic ovary syndrome on the medical
claims they submit to health insurers for reimbursement.
With widespread coding and documentation challenges involved, the support of an
experienced medical coding service provider can help in accurate submission of claims.
The ICD-10 codes for coding PCOS include -
E28.2 - Polycystic ovarian syndrome
In addition to undergoing the above treatment methods, incorporating serious lifestyle
changes can make a real difference and help relieve many of the prominent symptoms.
Eating a healthy, well-balanced diet (that includes fruits and vegetables) and engaging in
regular physical exercise/activity may help maintain or reduce body weight and obesity.
This in turn may reduce androgen levels and lessen the risk of lifestyle diseases such as
diabetes and heart disease.
The exact causes of PCOS are unclear, however early diagnosis can help alleviate symptoms
and reduce the risk of further complications.
The topic of Polycystic Ovary Syndrome (PCOS) holds immense significance during the
month of September in the United States - as September is observed as “Polycystic Ovary
Syndrome (PCOS) Awareness Month” every year in the US. Sponsored by the National
Polycystic Ovary Syndrome Association, the federally-designated event aims to improve the
lives of those women affected by PCOS and take steps to help them overcome their
symptoms as well as reduce their risk of suffering from life-threatening complications
(such as nonalcoholic fatty liver disease, cancer, diabetes and cardio-vascular diseases)
associated with the condition.
Join this month-long campaign to increase public knowledge and understanding about
Polycystic Ovary Syndrome (PCOS) and help those women/girls diagnosed with PCOS.