ICD-10 Coding for Uterine Prolapse(N81.3, N81.4, O34.529)
Complete ICD-10-CM coding and documentation guide for Uterine Prolapse. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Uterine Prolapse
N81.0-N81.9Primary Range
Female genital prolapse
This range includes all types of female genital prolapse, including uterine prolapse.
Maternal care for known or suspected abnormality of pelvic organs
Used when prolapse complicates childbirth.
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 the cervix is visibly protruding beyond the vaginal introitus. |
|
| N81.4 | Unspecified uterovaginal prolapse | Use when the prolapse is documented but not specified by stage. |
|
| O34.529 | Maternal care for prolapse of pelvic organs, 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 Uterine Prolapse
Primary ICD-10-CM Codes for uterine prolapse
Decision Criteria
clinical Criteria
- Cervix protrudes beyond vaginal introitus
Clinical Validation Requirements
- Cervix protrudes beyond vaginal introitus
- POP-Q Stage III or IV
Code-Specific Risks
- Incorrectly adding cystocele or rectocele codes due to Excludes1 note.
Coding Notes
- Ensure documentation specifies the stage and anatomical findings.
N81.4 - Unspecified uterovaginal prolapse
Use when the prolapse is documented but not specified by stage.
Clinical Validation Requirements
- General documentation without specific staging
Coding Notes
Encourage documentation of specific stage and findings.
O34.529 - Maternal care for prolapse of pelvic organs, unspecified trimester
Use when prolapse complicates childbirth.
Clinical Validation Requirements
- Prolapse diagnosed during childbirth
Coding Notes
Sequence first for obstetric-related prolapse.
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 Uterine Prolapse 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 patient records, Regulatory: Potential for coding audits, Financial: Incorrect reimbursement
Mitigation Strategy
Use detailed templates, Train staff on POP-Q system
Impact
Reimbursement: May lead to incorrect DRG assignment., Compliance: Violates coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Do not code cystocele separately due to Excludes1 note.
Impact
Incorrect coding of cystocele with uterine prolapse.
Mitigation Strategy
Educate coders on Excludes1 notes and proper code usage.
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 Uterine Prolapse, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Uterine Prolapse
Use these documentation templates to ensure complete and accurate documentation for Uterine Prolapse. These templates include all required elements for proper coding and billing.
Pelvic Exam for Uterine Prolapse
Specialty: GynecologyRequired Elements
- External inspection
- Speculum exam
- Bimanual exam
- POP-Q measurements
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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