ICD-10 Coding for Genital Prolapse(N81.0, N81.1, N81.2, N81.3, N81.6)
Complete ICD-10-CM coding and documentation guide for Genital Prolapse. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Genital Prolapse
N81Primary Range
Female genital prolapse
This range includes all types of female genital prolapse, such as cystocele, rectocele, and uterovaginal prolapse.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N81.0 | Urethrocele | Use when urethral prolapse is confirmed by physical examination. |
|
| N81.1 | Cystocele | Use when cystocele is confirmed by POP-Q measurements. |
|
| N81.2 | Incomplete uterovaginal prolapse | Use when uterine prolapse does not extend beyond the hymen. |
|
| N81.3 | Complete uterovaginal prolapse | Use when the uterus or cervix is completely prolapsed beyond the vaginal opening. |
|
| N81.6 | Rectocele | Use when rectocele is confirmed by physical examination. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for complete uterovaginal prolapse
Essential facts and insights about Genital Prolapse
Primary ICD-10-CM Codes for genital prolapse
Decision Criteria
clinical Criteria
- Urethral descent observed during physical exam
Applicable To
- Prolapse of urethra
Excludes
- Stress incontinence (N39.3)
Clinical Validation Requirements
- Physical exam showing urethral descent
- Patient reports urinary symptoms
Code-Specific Risks
- Confusion with stress incontinence coding
Coding Notes
- Ensure documentation specifies urethral descent.
N81.1 - Cystocele
Use when cystocele is confirmed by POP-Q measurements.
Applicable To
- Bladder prolapse
Excludes
- Vaginal vault prolapse (N99.3)
Clinical Validation Requirements
- POP-Q measurement showing anterior vaginal wall descent
- Patient reports urinary frequency or urgency
Coding Notes
Document specific POP-Q points for accurate staging.
N81.2 - Incomplete uterovaginal prolapse
Use when uterine prolapse does not extend beyond the hymen.
Applicable To
- Partial uterine prolapse
Excludes
- Complete uterovaginal prolapse (N81.3)
Clinical Validation Requirements
- Physical exam showing partial uterine descent
- Patient reports pelvic pressure
Coding Notes
Ensure documentation specifies the extent of prolapse.
N81.3 - Complete uterovaginal prolapse
Use when the uterus or cervix is completely prolapsed beyond the vaginal opening.
Applicable To
- Total uterine prolapse
Excludes
- Incomplete uterovaginal prolapse (N81.2)
Clinical Validation Requirements
- Physical exam showing cervix or uterus protruding beyond introitus
- Patient reports significant pelvic discomfort
Coding Notes
Document the extent of prolapse clearly.
N81.6 - Rectocele
Use when rectocele is confirmed by physical examination.
Applicable To
- Posterior vaginal wall prolapse
Excludes
- Enterocele (N81.5)
Clinical Validation Requirements
- POP-Q measurement showing posterior vaginal wall descent
- Patient reports difficulty with bowel movements
Coding Notes
Ensure documentation specifies posterior wall descent.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Genital Prolapse to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N81.0.
Impact
Clinical: Inadequate treatment planning, Regulatory: Non-compliance with documentation standards, Financial: Potential claim denials
Mitigation Strategy
Use specific anatomical terms, Include POP-Q measurements
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data recording.
Mitigation Strategy
Use N99.3 for vaginal vault prolapse post-hysterectomy.
Impact
Using unspecified codes when specific codes are applicable.
Mitigation Strategy
Ensure detailed documentation and use of specific codes.
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 Genital Prolapse, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Genital Prolapse
Use these documentation templates to ensure complete and accurate documentation for Genital Prolapse. These templates include all required elements for proper coding and billing.
Pelvic Organ Prolapse Evaluation
Specialty: GynecologyRequired Elements
- Patient history
- POP-Q measurements
- Physical exam findings
- Diagnostic imaging results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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