Find comprehensive information on rectal prolapse, including clinical documentation, ICD-10 codes (K62.1, K62.3), medical coding guidelines, healthcare provider resources, treatment options, symptoms like protrusion and bowel incontinence, and causes of complete or partial rectal prolapse. Learn about diagnosis, surgical repair procedures, and postoperative care for internal and external rectal prolapse. This resource is for healthcare professionals, medical coders, and patients seeking information on procidentia.
Also known as
Rectal prolapse
Complete or incomplete prolapse of the rectum.
Other diseases of anus and rectum
Includes anal fissure, fistula, abscess, and other rectal conditions.
Diseases of digestive system
Encompasses various disorders affecting the digestive tract.
Diseases of the digestive system
Broad category covering all digestive system diseases.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the rectal prolapse complete or incomplete?
Complete
Is it irreducible?
Incomplete
Is there mucosal prolapse only?
Not documented
Consider K62.9, unspecified rectal prolapse, if not otherwise specified.
When to use each related code
| Description |
|---|
| Rectal Prolapse |
| Hemorrhoids |
| Rectal Intussusception |
Coding rectal prolapse without specifying complete vs. incomplete or mucosal vs. full-thickness impacts DRG assignment and reimbursement.
Failing to code associated conditions like constipation, pelvic floor dysfunction, or prior surgeries can underestimate severity and complexity.
Miscoding internal intussusception or rectal mucosal prolapse as external rectal prolapse leads to inaccurate reporting and quality metrics.
Q: What are the most effective differential diagnostic considerations for full-thickness rectal prolapse in adults, considering both internal and external prolapse?
A: Differentiating full-thickness rectal prolapse (also known as complete rectal prolapse or procidentia) requires careful evaluation to exclude other anorectal conditions. Internal intussusception, mucosal prolapse, and internal rectal prolapse are key internal differentials. External differentials include hemorrhoids (both internal and external), rectal polyps, and even some forms of anorectal cancer. A thorough physical examination, including digital rectal exam and possibly proctoscopy or defecography, is crucial. Consider implementing dynamic imaging studies like defecography when the diagnosis remains unclear, especially to distinguish between internal intussusception and overt rectal prolapse. Explore how dynamic pelvic floor MRI can offer a less invasive approach to identifying the anatomical defects contributing to the prolapse. Accurate diagnosis is vital for effective management, which can range from conservative measures to surgical intervention depending on the specific condition.
Q: How can I distinguish between internal rectal prolapse (internal intussusception) and external rectal prolapse during clinical examination, and what specific maneuvers or diagnostic tools should I consider?
A: Distinguishing internal rectal prolapse (intussusception) from external rectal prolapse often presents a clinical challenge. While external prolapse is visually apparent as the rectum protrudes through the anus, internal prolapse may only be detected during straining or defecation. Digital rectal examination can sometimes palpate the intussusception as a thickened fold of rectal tissue. However, dynamic imaging techniques, such as defecography or dynamic pelvic floor MRI, are frequently essential for definitive diagnosis. Defecography provides real-time visualization of the defecation process, allowing for clear differentiation between internal and external prolapse. Explore the utility of dynamic pelvic floor MRI, which offers a less invasive alternative and may better delineate the anatomical structures involved. Learn more about the specific maneuvers during defecography, such as simulated defecation and straining, which can help elicit and characterize internal prolapse that might not be evident during routine physical examination.
Patient presents with complaints consistent with rectal prolapse, including protruding rectum, rectal bleeding, mucus discharge, and fecal incontinence. On examination, a full-thickness rectal prolapse was observed, with visible protrusion of rectal mucosa. The patient reported associated symptoms of constipation, straining during bowel movements, and a sensation of incomplete evacuation. Differential diagnosis includes internal intussusception, mucosal prolapse, and hemorrhoids. Severity of the prolapse was graded as (specify grade, e.g., Grade II, complete mucosal prolapse). The patient's medical history includes (relevant medical history, e.g., chronic constipation, prior pelvic surgery, multiparity). Current medications include (list current medications). Surgical intervention is being considered. Plan includes colonoscopy to rule out other pathologies and consultation with colorectal surgery. Patient education provided regarding bowel management, including high-fiber diet, increased fluid intake, and pelvic floor exercises. Follow-up scheduled in two weeks to reassess symptoms and discuss treatment options, including surgical repair such as rectopexy or resection. ICD-10 code K62.1 (Rectal prolapse) assigned. Procedure codes for evaluation and management, colonoscopy, and potential surgical intervention will be documented separately.