ICD-10 Coding for Vaginal Prolapse(N81.1, N81.6, N99.3)
Complete ICD-10-CM coding and documentation guide for Vaginal Prolapse. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Vaginal 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 |
|---|---|---|---|
| N81.1 | Cystocele | Use when a cystocele is confirmed via clinical examination or imaging. |
|
| N81.6 | Rectocele | Use when rectocele is confirmed via clinical examination or imaging. |
|
| N99.3 | Postprocedural vaginal vault prolapse | Use for vaginal vault prolapse occurring after hysterectomy. |
|
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 vaginal prolapse
Essential facts and insights about Vaginal Prolapse
Primary ICD-10-CM Codes for vaginal prolapse
Decision Criteria
clinical Criteria
- Presence of midline defect and POP-Q Ba point ≥ -1
Applicable To
- Midline defect of pubocervical fascia
Excludes
- Post-hysterectomy vault prolapse (N99.3)
Clinical Validation Requirements
- POP-Q Ba point ≥ -1
- Midline fascial tear
Code-Specific Risks
- Misclassification if not confirmed by POP-Q staging.
Coding Notes
- Ensure POP-Q measurements are documented.
N81.6 - Rectocele
Use when rectocele is confirmed via clinical examination or imaging.
Applicable To
- Herniation of rectum into vaginal canal
Excludes
- Post-hysterectomy vault prolapse (N99.3)
Clinical Validation Requirements
- POP-Q Ap point
- Defecography confirmation
Coding Notes
Document imaging findings clearly.
N99.3 - Postprocedural vaginal vault prolapse
Use for vaginal vault prolapse occurring after hysterectomy.
Applicable To
- Vaginal apex descent post-hysterectomy
Excludes
- Cystocele (N81.1)
- Rectocele (N81.6)
Clinical Validation Requirements
- Surgical history of hysterectomy
- Vaginal apex descent ≥50%
Coding Notes
Ensure surgical history is documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
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 Vaginal Prolapse to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N81.1.
Impact
Clinical: Leads to inappropriate treatment planning., Regulatory: Fails to meet documentation standards., Financial: Potential claim denials due to lack of specificity.
Mitigation Strategy
Use specific terms like 'cystocele' or 'rectocele'., Include POP-Q measurements.
Impact
Reimbursement: Incorrect coding may lead to claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use N99.3 for post-hysterectomy vault prolapse.
Impact
Using incorrect codes for specific prolapse types.
Mitigation Strategy
Regular training on prolapse coding guidelines.
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 Vaginal Prolapse, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Vaginal Prolapse
Use these documentation templates to ensure complete and accurate documentation for Vaginal Prolapse. These templates include all required elements for proper coding and billing.
Gynecology H&P for prolapse
Specialty: GynecologyRequired Elements
- Subjective symptoms
- Objective POP-Q measurements
- Assessment and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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