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N81.4
ICD-10-CM
Uterine Prolapse

Find comprehensive information on uterine prolapse, including clinical documentation, medical coding, ICD-10 codes, stages, symptoms, pelvic organ prolapse, treatment options, and diagnosis. Learn about healthcare best practices for documenting uterine prolapse and ensuring accurate medical coding for reimbursement. This resource provides essential information for healthcare professionals, medical coders, and patients seeking to understand uterine prolapse.

Also known as

Pelvic Organ Prolapse
Uterovaginal Prolapse

Diagnosis Snapshot

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

Related ICD-10 Code Ranges

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

Uterine prolapse

Covers various degrees of uterine descent into the vagina.

N81.0

Female genital prolapse, unspecified

General prolapse when a more specific type is unknown.

O00-O99

Pregnancy, childbirth and the puerperium

May include codes related to prolapse following delivery.

N99.3

Stress incontinence, female

Often associated with pelvic floor weakness and uterine prolapse.

Code-Specific Guidance

Decision Tree for

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

Is the prolapse incomplete?

  • Yes

    Is it first degree?

  • No

    Is it complete?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Uterine Prolapse
Cystocele
Rectocele

Documentation Best Practices

Documentation Checklist
  • Uterine prolapse stage (I-IV) using POP-Q.
  • Pelvic organ prolapse symptoms documented.
  • Anterior, posterior vaginal wall defects.
  • Impact on bladder/bowel function noted.
  • Associated conditions: cystocele, rectocele.

Mitigation Tips

Best Practices
  • Kegel exercises daily. ICD-10: N81.1. SNOMED: 385706009
  • Manage constipation. High-fiber diet. ICD-10: K59.0
  • Treat chronic cough. ICD-10: R05. SNOMED: 195704003
  • Avoid heavy lifting. CDI: Document activity restrictions.
  • Weight management. BMI monitoring. ICD-10: E66.9, Z68.43

Clinical Decision Support

Checklist
  • Confirm pelvic organ prolapse symptoms (POP)
  • Pelvic exam: Quantify prolapse stage (POP-Q)
  • Exclude other pelvic floor disorders
  • Document prolapse stage, impact on QOL

Reimbursement and Quality Metrics

Impact Summary
  • Uterine Prolapse Reimbursement: ICD-10 N81.1, CPT 57260 (surgical repair), impacting MS-DRG assignments.
  • Coding accuracy crucial for proper pelvic organ prolapse (POP) severity staging affecting reimbursement.
  • Hospital reporting: Prolapse stage impacts quality metrics like readmission rates for vaginal vault prolapse.
  • Accurate coding and documentation improve quality data for uterine prolapse treatment outcomes analysis.

Streamline Your Medical Coding

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

Quick Tips

Practical Coding Tips
  • Code prolapse stage, N81.x
  • Document pelvic exam findings
  • Specify site, anterior/posterior
  • Add supporting ICD-10 codes
  • Query physician if unclear

Documentation Templates

Patient presents with complaints consistent with uterine prolapse symptoms, including pelvic pressure, vaginal bulge, lower back pain, and urinary incontinence.  Physical examination reveals [stage of prolapse: first-degree, second-degree, third-degree, or complete procidentia] uterine prolapse.  The cervix is [location of cervix relative to the introitus:  at the introitus, within the vagina, or outside the vagina].  Pelvic floor muscle strength is assessed as [strength grading:  weak, fair, good, or excellent].  Anterior and posterior vaginal wall support are evaluated and documented as [presence or absence of cystocele or rectocele].  The patient's Baden-Walker halfway system score is [document score].  Differential diagnosis includes cystocele, rectocele, and enterocele.  Patient's medical history includes [relevant medical history such as prior pregnancies, vaginal deliveries, hysterectomy, pelvic surgeries, connective tissue disorders, chronic cough, obesity, menopause status, hormone replacement therapy].  The patient reports [impact on quality of life including sexual function, physical activity limitations].  Treatment options discussed include conservative management with pelvic floor exercises, pessary fitting, and surgical intervention such as hysterectomy, sacrocolpopexy, uterosacral ligament suspension, or anterior and posterior colporrhaphy.  Patient education provided on pelvic floor health, lifestyle modifications including weight management and bowel habits, and potential risks and benefits of each treatment option.  Follow-up scheduled for [date of follow-up] to reassess symptoms and discuss treatment plan.  ICD-10 code N81.1 (Uterine prolapse, unspecified) is assigned.
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