ICD-10 Coding for Uterovaginal Prolapse(N81.3, N81.2)
Complete ICD-10-CM coding and documentation guide for Uterovaginal Prolapse. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Uterovaginal Prolapse
N81.2-N81.3Primary Range
ICD-10 codes for uterovaginal prolapse
These codes cover both complete and incomplete uterovaginal 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 the uterus and vaginal apex protrude beyond the hymen. |
|
| N81.2 | Incomplete uterovaginal prolapse | Use when the uterus descends to the hymen but does not protrude. |
|
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 complete uterovaginal prolapse
Essential facts and insights about Uterovaginal Prolapse
Primary ICD-10-CM Codes for uterovaginal prolapse
Decision Criteria
clinical Criteria
- Uterus and vaginal apex protrude beyond hymen
documentation Criteria
- POP-Q point C ≥ +1cm
Applicable To
- Complete descent of uterus and vaginal apex beyond hymen
Clinical Validation Requirements
- POP-Q point C ≥ +1cm
- MRI showing uterus below pubococcygeal line
- Patient reports visible vaginal bulge
Code-Specific Risks
- Using N81.3 without POP-Q measurements
- Incorrectly coding as unspecified
Coding Notes
- Ensure documentation includes POP-Q measurements and specific prolapse details.
N81.2 - Incomplete uterovaginal prolapse
Use when the uterus descends to the hymen but does not protrude.
Applicable To
- Uterus descends to hymen but does not protrude
Excludes
- Vaginal vault prolapse (N99.3)
Clinical Validation Requirements
- POP-Q point C 0 to +1cm
- Ultrasound: cervix at hymen level
Coding Notes
Ensure documentation specifies the extent of prolapse.
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 Uterovaginal 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: May lead to inappropriate treatment plans., Regulatory: Increases risk of audit issues., Financial: Potential for denied claims.
Mitigation Strategy
Use standardized templates for documentation., Ensure all clinical staff are trained on POP-Q system.
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Increases risk of audit failures., Data Quality: Reduces accuracy of clinical data.
Mitigation Strategy
Ensure detailed documentation supports the specific code.
Impact
Inadequate documentation of prolapse extent can lead to audit findings.
Mitigation Strategy
Use detailed templates and ensure all measurements are recorded.
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 Uterovaginal Prolapse, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Uterovaginal Prolapse
Use these documentation templates to ensure complete and accurate documentation for Uterovaginal Prolapse. These templates include all required elements for proper coding and billing.
Complete uterovaginal prolapse assessment
Specialty: GynecologyRequired Elements
- POP-Q measurements
- Detailed prolapse description
- Associated symptoms
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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