ICD-10 Coding for Prolapsed Uterus(N81.3, N81.2, N81.4)
Complete ICD-10-CM coding and documentation guide for Prolapsed Uterus. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Prolapsed Uterus
N81.2-N81.4Primary Range
Codes for uterovaginal prolapse
These codes cover the spectrum of uterovaginal prolapse from incomplete to complete and unspecified 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 |
|---|---|---|---|
| N81.3 | Complete uterovaginal prolapse | Use when the prolapse is complete, with cervix or vaginal wall protruding beyond the hymen. |
|
| N81.2 | Incomplete uterovaginal prolapse | Use when prolapse is partial, not extending beyond the hymen. |
|
| N81.4 | Unspecified uterovaginal prolapse | Use when documentation lacks specific details to classify as complete or incomplete. |
|
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 prolapsed uterus
Essential facts and insights about Prolapsed Uterus
Primary ICD-10-CM Codes for prolapsed uterus
Decision Criteria
clinical Criteria
- Cervix or vaginal wall extends beyond hymen
documentation Criteria
- POP-Q Stage III/IV measurements documented
Applicable To
- Third-degree prolapse
- Procidentia
Excludes
- N81.6 Rectocele
Clinical Validation Requirements
- Cervix protruding beyond hymenal ring
- POP-Q Stage III/IV measurements
Code-Specific Risks
- Incorrectly coding with N81.6 for rectocele when it is included in N81.3
Coding Notes
- Ensure documentation specifies complete prolapse with anatomical landmarks.
N81.2 - Incomplete uterovaginal prolapse
Use when prolapse is partial, not extending beyond the hymen.
Applicable To
- Second-degree prolapse
Excludes
- N81.3 Complete uterovaginal prolapse
Clinical Validation Requirements
- Midvaginal descent
- POP-Q Stage II measurements
Coding Notes
Ensure documentation specifies incomplete prolapse with anatomical landmarks.
N81.4 - Unspecified uterovaginal prolapse
Use when documentation lacks specific details to classify as complete or incomplete.
Clinical Validation Requirements
- Generic uterine prolapse without specific anatomical details
Coding Notes
Encourage detailed documentation to avoid using unspecified codes.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Stress incontinence
N39.3Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Prolapsed Uterus to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N81.3.
Impact
Clinical: Loss of detailed clinical information, Regulatory: Increased audit risk, Financial: Potential reimbursement issues
Mitigation Strategy
Ensure detailed documentation, Use specific codes when possible
Impact
Reimbursement: May lead to incorrect DRG assignment, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate clinical data representation
Mitigation Strategy
Use N81.3 alone if rectocele is part of the complete prolapse.
Impact
Increased risk of audits due to lack of specificity.
Mitigation Strategy
Encourage 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 Prolapsed Uterus, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Prolapsed Uterus
Use these documentation templates to ensure complete and accurate documentation for Prolapsed Uterus. These templates include all required elements for proper coding and billing.
Complete uterovaginal prolapse with cystocele
Specialty: GynecologyRequired Elements
- Cervix protrusion measurement
- POP-Q Stage
- Functional impact
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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