ICD-10 Coding for Rectocele(N81.6)
Complete ICD-10-CM coding and documentation guide for Rectocele. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Rectocele
N81.6Primary Range
Female genital prolapse
This range includes the primary ICD-10 code for rectocele, which is a type of pelvic organ prolapse.
Key Information: ICD-10 code for rectocele
Essential facts and insights about Rectocele
Primary ICD-10-CM Code for rectocele
Decision Criteria
clinical Criteria
- Presence of vaginal bulge and symptoms like constipation
documentation Criteria
- Detailed operative note specifying approach and mesh use
Clinical Validation Requirements
- Vaginal bulge
- Constipation requiring splinting
- Dyspareunia
Code-Specific Risks
- Excludes1 note with uterine prolapse codes
Coding Notes
- Ensure documentation specifies the approach and use of mesh if applicable.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site
57267Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Vaginal enterocele
N81.5Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Rectocele to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N81.6.
Impact
Clinical: Inaccurate representation of surgical procedure, Regulatory: Potential audit risk, Financial: Loss of reimbursement for mesh use
Mitigation Strategy
Use standardized templates, Checklist for operative notes
Impact
Reimbursement: Incorrect DRG assignment leading to reimbursement issues., Compliance: Violation of ICD-10 coding rules., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Ensure N81.6 is not used with N81.2-N81.4 due to Excludes1 note.
Impact
Using N81.6 with uterine prolapse codes.
Mitigation Strategy
Implement EHR hard stops for Excludes1 pairs.
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 Rectocele, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Rectocele
Use these documentation templates to ensure complete and accurate documentation for Rectocele. These templates include all required elements for proper coding and billing.
Rectocele repair with mesh
Specialty: GynecologyRequired Elements
- Procedure description
- Approach used
- Mesh details
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Rectocele? Ask your questions below.