Uterovaginal prolapse, unspecified
ICD-10 N81.4 is a billable code used to indicate a diagnosis of uterovaginal prolapse, unspecified.
Uterovaginal prolapse is a condition where the uterus and vagina descend into the vaginal canal due to weakened pelvic support structures. This condition can arise from various factors, including childbirth, aging, obesity, and chronic cough. Symptoms may include a sensation of heaviness or pressure in the pelvic area, urinary incontinence, and difficulty with bowel movements. Uterovaginal prolapse can be classified into different types, such as cystocele (anterior wall prolapse), rectocele (posterior wall prolapse), and uterine prolapse. The unspecified designation in N81.4 indicates that the specific type of prolapse has not been documented, which can complicate treatment and management. It is essential for healthcare providers to conduct a thorough assessment to determine the extent of the prolapse and any associated conditions, such as endometriosis, which can exacerbate pelvic pain and discomfort. Additionally, the presence of pelvic floor disorders, including fistulas and ovarian disorders, may influence the treatment approach. Accurate coding is crucial for appropriate management and reimbursement.
Detailed pelvic examination findings, patient history, and symptomatology.
Patients presenting with pelvic pressure, urinary incontinence, or vaginal bulging.
Ensure clear documentation of the type and severity of prolapse for accurate coding.
Assessment of urinary symptoms and any associated urological conditions.
Patients with urinary incontinence related to pelvic organ prolapse.
Document any urodynamic studies performed to support diagnosis.
Used when surgical intervention is performed for cystocele associated with uterovaginal prolapse.
Document the type of prolapse and surgical details.
Ensure alignment with gynecological assessments.
Document the patient's symptoms, examination findings, and any associated conditions. If the type of prolapse is not specified, ensure that this is clearly noted in the medical record.
