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v1.0.0
ICD-10 Guide
ICD-10 CodesN81.5

N81.5

Billable

Vinal enterocele

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/18/2025

Code Description

ICD-10 N81.5 is a billable code used to indicate a diagnosis of vinal enterocele.

Key Diagnostic Point:

Vaginal enterocele is a condition characterized by the herniation of the small intestine into the vaginal canal, typically occurring in women who have experienced pelvic floor weakening due to childbirth, aging, or other factors. This condition is often associated with other forms of pelvic organ prolapse, including cystocele (bladder prolapse) and rectocele (rectal prolapse). Patients may present with symptoms such as pelvic pressure, vaginal bulging, urinary incontinence, or difficulty with bowel movements. The diagnosis is usually made through a physical examination, where a bulge may be observed during a Valsalva maneuver. Imaging studies, such as MRI or ultrasound, may be utilized for further evaluation. Treatment options vary based on the severity of symptoms and may include pelvic floor exercises, pessary placement, or surgical intervention. Understanding the relationship between vaginal enterocele and other conditions like endometriosis, female genital prolapse, and ovarian disorders is crucial for comprehensive management and accurate coding.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between various types of pelvic organ prolapse.
  • Understanding associated conditions such as endometriosis and ovarian disorders.
  • Documentation requirements for surgical interventions.
  • Variability in symptoms and clinical presentation.

Audit Risk Factors

  • Inadequate documentation of symptoms and clinical findings.
  • Failure to document associated conditions.
  • Incorrect coding of the type of prolapse.
  • Lack of clarity in surgical documentation.

Specialty Focus

Medical Specialties

Obstetrics and Gynecology

Documentation Requirements

Detailed notes on patient history, physical examination findings, and treatment plans.

Common Clinical Scenarios

Patients presenting with pelvic pain, urinary incontinence, or vaginal bulging.

Billing Considerations

Ensure accurate documentation of any surgical procedures performed and their indications.

Urology

Documentation Requirements

Comprehensive assessment of urinary symptoms and any related surgical interventions.

Common Clinical Scenarios

Patients with urinary incontinence or obstructive urinary symptoms related to pelvic organ prolapse.

Billing Considerations

Collaboration with gynecologists for comprehensive management of prolapse.

Coding Guidelines

Inclusion Criteria

Use N81.5 When
  • Follow the official ICD
  • CM guidelines for coding and reporting, ensuring accurate documentation of the condition and any associated diagnoses
  • Include details on the type of prolapse and any relevant surgical procedures

Exclusion Criteria

Do NOT use N81.5 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

57260CPT Code

Repair of enterocele

Clinical Scenario

Used when surgical intervention is performed for vaginal enterocele.

Documentation Requirements

Detailed operative notes and pre-operative assessments.

Specialty Considerations

Ensure collaboration between gynecology and urology for comprehensive care.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of vaginal enterocele, improving the accuracy of data collection and reimbursement processes. This specificity aids in better understanding the prevalence and treatment outcomes of this condition.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of vaginal enterocele, improving the accuracy of data collection and reimbursement processes. This specificity aids in better understanding the prevalence and treatment outcomes of this condition.

Reimbursement & Billing Impact

reimbursement processes. This specificity aids in better understanding the prevalence and treatment outcomes of this condition.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What are the common symptoms of vaginal enterocele?

Common symptoms include pelvic pressure, vaginal bulging, urinary incontinence, and difficulty with bowel movements.

How is vaginal enterocele diagnosed?

Diagnosis is typically made through a physical examination, often during a Valsalva maneuver, and may include imaging studies for further evaluation.