ICD-10 Coding for Prolapse of Uterus(N81.3, N81.4, N81.9, O34.529)
Complete ICD-10-CM coding and documentation guide for Prolapse of Uterus. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Prolapse of Uterus
N81Primary Range
Female genital prolapse
This range includes all types of female genital prolapse, including uterine prolapse.
Maternal care for known or suspected uterine prolapse
Used for prolapse complicating childbirth.
Postprocedural disorders of genitourinary system
Includes post-hysterectomy vaginal vault 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 |
|---|---|---|---|
| N81.3 | Complete uterovaginal prolapse | Use when there is complete descent of the uterus into the vaginal canal. |
|
| N81.4 | Incomplete uterovaginal prolapse | Use when there is partial descent of the uterus. |
|
| N81.9 | Female genital prolapse, unspecified | Use when documentation does not specify the type or stage of prolapse. |
|
| O34.529 | Maternal care for known or suspected uterine prolapse, unspecified trimester | Use when prolapse complicates childbirth. |
|
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 uterine prolapse
Essential facts and insights about Prolapse of Uterus
Primary ICD-10-CM Codes for prolapse of uterus
Decision Criteria
clinical Criteria
- Complete descent of uterus into vaginal canal
coding Criteria
- Avoid using with N81.1 or N81.6 unless specified
Applicable To
- Complete prolapse of uterus
Excludes
- Post-hysterectomy vaginal vault prolapse (N99.3)
N81.4 - Incomplete uterovaginal prolapse
Use when there is partial descent of the uterus.
Applicable To
- Partial prolapse of uterus
Excludes
- Complete uterovaginal prolapse (N81.3)
Clinical Validation Requirements
- POP-Q measurements indicating partial descent
- Symptoms of pelvic pressure without complete descent
Coding Notes
Ensure documentation specifies incomplete prolapse.
N81.9 - Female genital prolapse, unspecified
Use when documentation does not specify the type or stage of prolapse.
Excludes
- Complete uterovaginal prolapse (N81.3)
- Incomplete uterovaginal prolapse (N81.4)
Clinical Validation Requirements
- General symptoms of prolapse without specific staging
Coding Notes
Query for specificity if possible.
O34.529 - Maternal care for known or suspected uterine prolapse, unspecified trimester
Use when prolapse complicates childbirth.
Applicable To
- Prolapse complicating childbirth
Clinical Validation Requirements
- Prolapse noted during pregnancy or childbirth
Coding Notes
Ensure documentation links prolapse to childbirth.
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 Prolapse of Uterus to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N81.3.
Impact
Clinical: Inaccurate assessment of prolapse severity., Regulatory: Potential non-compliance with coding standards., Financial: May lead to denied claims or reduced reimbursement.
Mitigation Strategy
Use POP-Q system for detailed documentation., Ensure complete operative notes.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Violates coding guidelines for exclusivity., Data Quality: Leads to inaccurate clinical data representation.
Mitigation Strategy
Use N81.3 alone unless defects are distinct and unrelated.
Impact
Reimbursement: May affect DRG assignment and payment., Compliance: Incorrect post-surgical coding., Data Quality: Misrepresents the clinical scenario.
Mitigation Strategy
Use N81.1 for cystocele post-hysterectomy, not N99.3.
Impact
Risk of incorrect code selection or sequencing.
Mitigation Strategy
Regular training on ICD-10 guidelines and updates.
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 Prolapse of Uterus, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Prolapse of Uterus
Use these documentation templates to ensure complete and accurate documentation for Prolapse of Uterus. These templates include all required elements for proper coding and billing.
Surgical repair of uterine prolapse
Specialty: GynecologyRequired Elements
- Pre-operative diagnosis
- Surgical approach
- Findings and procedures
- Post-operative diagnosis
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Prolapse of Uterus? Ask your questions below.