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
Uterine prolapse
Covers various degrees of uterine descent into the vagina.
Female genital prolapse, unspecified
General prolapse when a more specific type is unknown.
Pregnancy, childbirth and the puerperium
May include codes related to prolapse following delivery.
Stress incontinence, female
Often associated with pelvic floor weakness and uterine prolapse.
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?
When to use each related code
Description |
---|
Uterine Prolapse |
Cystocele |
Rectocele |
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.