ICD-10 Coding for Pelvic Floor Dysfunction(M99.05, N81.84, N94.2)
Complete ICD-10-CM coding and documentation guide for Pelvic Floor Dysfunction. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Pelvic Floor Dysfunction
M99.05Primary Range
Segmental and somatic dysfunction of pelvic region
Primary code for hypertonic pelvic floor dysfunction with symptoms such as pain and limited mobility.
Pelvic muscle wasting (disuse atrophy)
Used for conditions involving pelvic muscle weakness and atrophy.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M99.05 | Segmental and somatic dysfunction of pelvic region | Use when there is evidence of hypertonicity and pain in the pelvic region. |
|
| N81.84 | Pelvic muscle wasting (disuse atrophy) | Use for conditions involving muscle weakness and atrophy. |
|
| N94.2 | Vulvodynia | Use for chronic vulvar pain with negative infection tests. |
|
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 pelvic floor dysfunction
Essential facts and insights about Pelvic Floor Dysfunction
Primary ICD-10-CM Codes for pelvic floor dysfunction
Decision Criteria
clinical Criteria
- Presence of hypertonicity and pain in pelvic region.
Applicable To
- Pelvic floor dysfunction
- Hypertonic pelvic floor
Excludes
- Pelvic muscle wasting (N81.84)
Clinical Validation Requirements
- Palpable hypertonicity in obturator internus
- Trigger points at 3 and 9 o’clock
- Pain with transvaginal pressure ≥4/10
Code-Specific Risks
- Incorrectly coding as general pelvic pain without specifying dysfunction.
Coding Notes
- Ensure documentation includes specific symptoms and exam findings.
N81.84 - Pelvic muscle wasting (disuse atrophy)
Use for conditions involving muscle weakness and atrophy.
Applicable To
- Pelvic muscle weakness
Excludes
- Hypertonic pelvic floor (M99.05)
Clinical Validation Requirements
- Manual muscle testing ≤2/5 strength
- History of prolonged bed rest
Coding Notes
Document muscle testing results and history of disuse.
N94.2 - Vulvodynia
Use for chronic vulvar pain with negative infection tests.
Applicable To
- Vulvar pain
Excludes
- Infections of the vulva
Clinical Validation Requirements
- Vulvar point tenderness at 5 o’clock
- Pain persists ≥3 months
- Negative cultures for infection
Coding Notes
Ensure exclusion of infections is documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Pelvic and perineal pain
R10.2Differential 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 Pelvic Floor Dysfunction to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M99.05.
Impact
Clinical: Leads to misdiagnosis., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Use specific clinical terms, Include diagnostic test results
Impact
Reimbursement: May lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data on pelvic conditions.
Mitigation Strategy
Link R10.2 to M99.05 for specific dysfunction.
Impact
Lack of documentation for failed PFMT.
Mitigation Strategy
Maintain detailed exercise logs and SEMG results.
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 Pelvic Floor Dysfunction, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Pelvic Floor Dysfunction
Use these documentation templates to ensure complete and accurate documentation for Pelvic Floor Dysfunction. These templates include all required elements for proper coding and billing.
Hypertonic pelvic floor dysfunction
Specialty: Physical TherapyRequired Elements
- Subjective symptoms
- Objective findings
- Assessment
- Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Pelvic Floor Dysfunction? Ask your questions below.