Here’s what provider needs to provide in his or her documentation.
Menopause that occurs before the age of 40, whether natural or induced, is called ‘premature” menopause. A woman with premature menopause may deal with hot flashes, mood swings, and other symptoms that accompany menopause. Currently, you’ll report this with 256.31 (Premature menopause).
When your diagnosis system changes, your coding choice will expand into two options dependent on whether the patient is symptomatic (E28.310, Symptomatic premature menopause) or asymptomatic (E28.319, Asymptomatic premature menopause).
Documentation tips: Underneath the entry for symptomatic premature menopause, you’ll see the following note: ‘Symptoms such as flushing, sleeplessness, headache, lack of concentration, associated with premature menopause.” Therefore, the provider should document that the patient is experiencing these symptoms so that the coder can report E28.310.
Coder’s tips: Make certain you read your physician documentation to determine whether the patient has symptoms of premature menopause (E28.310) or is not experiencing any symptoms with her premature menopause (E28.319).
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