ICD-10 Guide

Abnormal Uterine Bleeding

ICD-10 Coding for Abnormal Uterine Bleeding(N93.9, D25.0)

PRIMARY SPECIALTYGynecology

COMPLEXITYHigh

LAST UPDATED09/15/2025

Sam Tuffun, PT, DPT

Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Abnormal Uterine Bleeding?

Abnormal Uterine Bleeding (AUB) is defined as any bleeding from the uterus that deviates from normal menstrual patterns. Key clinical points include: 1) AUB can be classified into various types, including menorrhagia, metrorrhagia, and oligomenorrhea. 2) Common etiologies include hormonal imbalances, uterine fibroids, polyps, and malignancies. 3) Clinical presentation may involve heavy menstrual bleeding, irregular cycles, or bleeding between periods. 4) Diagnosis often requires a thorough history, physical examination, and may include imaging studies or endometrial biopsy. Typical use cases for this diagnosis code include patients presenting with heavy menstrual bleeding or irregular cycles that warrant further investigation. The pathophysiology often involves disruptions in the hypothalamic-pituitary-ovarian axis, leading to abnormal endometrial proliferation and shedding. Clinically, patients may report fatigue, anemia, or pelvic discomfort due to excessive blood loss.

Key Clinical Considerations:

Diagnosis of AUB requires a detailed patient history and physical examination, including menstrual history and any associated symptoms.
Signs and symptoms include heavy menstrual bleeding, prolonged bleeding, bleeding between periods, and pelvic pain.
Resolution criteria may include normalization of menstrual cycles or cessation of abnormal bleeding following treatment.
Laboratory findings may include complete blood count (CBC) to assess for anemia, and imaging studies such as ultrasound to evaluate for structural abnormalities.

Clinical Information

Clinical Criteria & Documentation Requirements

Essential documentation includes a clear description of the patient's symptoms, duration of bleeding, and any relevant medical history.
Compliant documentation examples include detailed menstrual history and results from diagnostic tests; non-compliant documentation may lack specificity or omit relevant findings.
Documentation template phrases include: 'Patient reports heavy menstrual bleeding for the past 3 months' or 'Ultrasound shows uterine fibroids.'
Medical necessity documentation requires justification for diagnostic tests and treatments based on clinical guidelines.

Coding Guidelines

Usage Guidelines & Examples

Use this code when a patient presents with abnormal bleeding patterns that require further evaluation, such as heavy menstrual bleeding or intermenstrual bleeding.
Do NOT use this code for normal menstrual variations or bleeding due to pregnancy-related conditions.
Correct usage example: 'Patient diagnosed with AUB after presenting with menorrhagia'; incorrect usage: 'Patient with normal menstrual cycle coded as AUB.'
Common coding errors include misclassifying normal variations as AUB; avoid this by ensuring thorough documentation of symptoms.

Code Exclusions

Important Exclusions

Excluded conditions include pregnancy-related bleeding (O20) and bleeding due to trauma or surgical procedures.
Alternative codes for exclusions may include O20 for threatened abortion or O21 for hyperemesis gravidarum.
Common exclusion errors include coding AUB for pregnancy-related bleeding; ensure clear documentation of the patient's status.
Certain conditions are excluded to ensure accurate coding and reimbursement, focusing on non-pregnancy-related causes of bleeding.

Specialty Focus

Primary Specialty

Gynecology

Specialty Applications

This diagnosis applies to conditions such as menorrhagia, oligomenorrhea, and intermenstrual bleeding.
Clinical scenarios include patients with heavy bleeding requiring evaluation for underlying causes.
Applicable in various practice settings including outpatient gynecology clinics, emergency departments, and inpatient settings.
Specialty-specific considerations include the need for gynecological evaluation and potential referral for surgical intervention.

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

Comprehensive clinical documentation
Accurate code selection based on clinical criteria
Proper exclusion considerations
Specialty-specific coding guidelines

Documentation

Documentation Templates

Template 1

Template: 'Abnormal uterine bleeding diagnosed based on patient history and ultrasound findings.'

Template 2

Template: 'Patient presents with heavy menstrual bleeding consistent with abnormal uterine bleeding diagnosis.'

Template 3

Template: 'Diagnostic criteria met: Menstrual cycle irregularities and ultrasound findings of fibroids.'

Template 4

Template: 'Treatment plan includes hormonal therapy for abnormal uterine bleeding.'

Billing Information

Billing Considerations

Ensure proper documentation for billing
Verify code specificity requirements
Check for any additional codes needed
Review payer-specific guidelines

Common Issues

Insufficient clinical documentation
Incorrect code selection
Missing supporting diagnoses
Timing and frequency documentation

Frequently Asked Questions

What documentation is required for this code?

Detailed documentation should include patient history, symptom description, and results from any diagnostic tests.

When should this code be used vs similar codes?

Use this code specifically for abnormal uterine bleeding not related to pregnancy; similar codes may apply to other gynecological conditions.

What are common billing issues with this code?

Common issues include claim denials due to insufficient documentation; ensure all clinical findings are well-documented.

What procedures are commonly associated?

Related CPT codes may include pelvic ultrasound (76856) and endometrial biopsy (58100), which may be necessary for diagnosis.

What is Abnormal Uterine Bleeding?

Key Clinical Considerations:

Diagnosis of AUB requires a detailed patient history and physical examination, including menstrual history and any associated symptoms.
Signs and symptoms include heavy menstrual bleeding, prolonged bleeding, bleeding between periods, and pelvic pain.
Resolution criteria may include normalization of menstrual cycles or cessation of abnormal bleeding following treatment.
Laboratory findings may include complete blood count (CBC) to assess for anemia, and imaging studies such as ultrasound to evaluate for structural abnormalities.

Abnormal Uterine Bleeding

Diagnosis Overview

Key Clinical Considerations:

Clinical Information

Clinical Criteria & Documentation Requirements

Coding Guidelines

Usage Guidelines & Examples

Code Exclusions

Important Exclusions

Related ICD-10 Codes

Related CPT Codes

Specialty Focus

Primary Specialty

Specialty Applications

Coding Complexity

Documentation

Documentation Templates

Template 1

Template 2

Template 3

Template 4

Billing Information

Billing Considerations

Common Issues

Frequently Asked Questions

What documentation is required for this code?

When should this code be used vs similar codes?

What are common billing issues with this code?

What procedures are commonly associated?

Abnormal Uterine Bleeding

Diagnosis Overview

Key Clinical Considerations:

Clinical Information

Clinical Criteria & Documentation Requirements

Coding Guidelines

Usage Guidelines & Examples

Code Exclusions

Important Exclusions

Related ICD-10 Codes

Related CPT Codes

Specialty Focus

Primary Specialty

Specialty Applications

Coding Complexity

Documentation

Documentation Templates

Template 1

Template 2

Template 3

Template 4

Billing Information

Billing Considerations

Common Issues

Frequently Asked Questions

What documentation is required for this code?

When should this code be used vs similar codes?

What are common billing issues with this code?

What procedures are commonly associated?