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N81.4
ICD-10-CM
Prolapse of Uterus

Find information on prolapse of uterus including uterine prolapse stages, pelvic organ prolapse treatment, and prolapse symptoms. This resource covers clinical documentation requirements for ICD-10 codes related to uterine prolapse and cystocele, rectocele diagnosis. Learn about medical coding for pelvic floor disorders and healthcare management options for genital prolapse. Explore surgical and non-surgical treatments, risk factors, and post-operative care for prolapsed uterus.

Also known as

Uterine Prolapse
Pelvic Organ Prolapse

Diagnosis Snapshot

Key Facts
  • Definition : Descent of the uterus into or through the vagina.
  • Clinical Signs : Pelvic pressure, vaginal bulge, urinary issues, low back pain, or sexual dysfunction.
  • Common Settings : Gynecology clinic, urogynecology clinic, or primary care office.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC N81.4 Coding
N81.1-N81.8

Uterine prolapse

Prolapse of uterus and uterine cervix

N81.0

Cystocele

Hernia of bladder wall into vagina

N81.2

Rectocele

Hernia of rectum into vagina

N99.3

Postoperative pelvic floor relaxation

Relaxation of pelvic floor after surgery

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the prolapse incomplete?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Uterine Prolapse
Cystocele
Rectocele

Documentation Best Practices

Documentation Checklist
  • Uterus prolapse stage (I-IV)
  • Pelvic organ prolapse quantification using POP-Q
  • Anterior, posterior, or apical prolapse documentation
  • Symptoms: urinary, bowel, sexual, or pelvic pressure
  • Associated conditions: cystocele, rectocele, enterocele

Coding and Audit Risks

Common Risks
  • Unspecified Prolapse

    Coding with N81.1, unspecified uterine prolapse, when documentation supports a more specific diagnosis like incomplete or complete prolapse.

  • Stage Miscoding

    Incorrectly assigning prolapse stage (e.g., N81.2, N81.3) due to inaccurate interpretation of pelvic exam findings or lack of clear documentation.

  • Associated Cystocele

    Failing to code associated conditions like cystocele (N81.0) when documented, impacting DRG assignment and reimbursement.

Mitigation Tips

Best Practices
  • ICD-10 N81.1, precise staging key to compliant billing
  • Detailed pelvic exam docs, quantify prolapse for accurate CDI
  • Kegels, pessaries: Document treatment, monitor response for HCC coding
  • Surgical plans: Mesh vs native repair impacts DRG assignment, justify
  • Post-op complications: ICD-10 coding specificity crucial for reimbursements

Clinical Decision Support

Checklist
  • Confirm pelvic organ prolapse symptoms (POP)
  • Visualize/palpate prolapse during pelvic exam
  • Quantify prolapse stage using POP-Q system
  • Document impact on QOL (quality of life)
  • Assess for other pelvic floor disorders

Reimbursement and Quality Metrics

Impact Summary
  • ICD-10 N81.1, N81.2, N81.3, N81.4, N81.5, N81.6, N81.8, N81.9: accurate coding impacts reimbursement.
  • POA indicator Y, N, U, W: correct reporting affects hospital case mix index.
  • Surgical procedures, eg hysterectomy, suspension: coding specificity maximizes payment.
  • Uterine prolapse stage documentation: complete clinical data improves quality metrics.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code prolapse stage, N81.x
  • Document supporting symptoms
  • Add laterality if applicable
  • Specify if complete/incomplete
  • Check for/code related cystocele/rectocele

Documentation Templates

Patient presents with complaints consistent with pelvic organ prolapse, specifically uterine prolapse.  Symptoms include vaginal pressure or fullness, sensation of a bulge or something "falling out," lower back pain, dyspareunia, urinary incontinence or frequency, and difficulty with bowel movements.  Pelvic examination reveals [Stage of prolapse: I, II, III, or IV] uterine prolapse.  Anterior and posterior vaginal walls were assessed for cystocele and rectocele, respectively.  The Baden-Walker Halfway system or the Pelvic Organ Prolapse Quantification system (POP-Q) was used to quantify the degree of prolapse.  Patient's medical history includes [relevant medical history e.g., multiparity, chronic cough, obesity, connective tissue disorders, prior pelvic surgery].  Differential diagnoses considered include cystocele, rectocele, enterocele, and urethral diverticulum.  Patient education was provided regarding pelvic floor exercises (Kegel exercises), pessary fitting as a conservative management option, and surgical management options including hysterectomy, uterosacral ligament suspension, sacrospinous ligament fixation, or anterior and posterior colporrhaphy if indicated.  Risks and benefits of each treatment option were discussed.  Plan is to [mention next steps such as scheduling for pessary fitting, urodynamic studies, or surgical consultation].  ICD-10 code N81.1 (Uterine prolapse) and associated procedure codes if applicable will be used for billing and coding purposes.  Follow-up scheduled in [timeframe].