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v1.0.0
ICD-10 Guide
DiagnosesPelvic Floor Dysfunction

Pelvic Floor Dysfunction

ICD-10 Coding for Pelvic Floor Dysfunction(M99.05, N81.84, N94.2)

PRIMARY SPECIALTYPhysical Therapy
COMPLEXITYHigh
LAST UPDATED09/15/2025
Sam Tuffun, PT, DPT
Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Pelvic Floor Dysfunction?
Essential facts and insights about Pelvic Floor Dysfunction

Key Clinical Considerations:

  • Urinary incontinence
  • Fecal incontinence
  • Pelvic pain
  • Difficulty with bowel or bladder control
  • Prolapse of pelvic organs

Clinical Information

Clinical Criteria & Documentation Requirements

  • Patient history and symptom description
  • Physical examination findings related to pelvic floor
  • Results of diagnostic tests (e.g., urodynamics)
  • Treatment plan and response to therapy

Coding Guidelines

Usage Guidelines & Examples

  • Ensure correct code selection based on specific symptoms and findings.
  • Common errors include using unspecified codes when more specific codes are available.

Code Exclusions

Important Exclusions

  • Pregnancy-related pelvic floor issues
  • Neurological conditions affecting pelvic function

Related ICD-10 Codes

Primary Codes
N81.9
Pelvic floor dysfunction, unspecified
N39.3
Stress incontinence (female)
K62.5
Fecal incontinence
Ancillary Codes
R10.2
Differential Codes
N81.84
N81.84
for muscle weakness and atrophy, not hypertonicity.
M99.05
M99.05
for hypertonicity, not muscle wasting.

Related CPT Codes

CPT codes will be available in a future update.

Specialty Focus

Primary Specialty

Physical Therapy

Specialty Applications

  • Adult and pediatric populations with pelvic floor issues
  • Outpatient physical therapy settings

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

  • Comprehensive clinical documentation
  • Accurate code selection based on clinical criteria
  • Proper exclusion considerations
  • Specialty-specific coding guidelines

Documentation

Documentation Templates

Billing Information

Billing Considerations

  • Ensure proper documentation for billing
  • Verify code specificity requirements
  • Check for any additional codes needed
  • Review payer-specific guidelines

Common Issues

  • Insufficient clinical documentation
  • Incorrect code selection
  • Missing supporting diagnoses
  • Timing and frequency documentation

Frequently Asked Questions

Documentation requirements?

Include detailed patient history, physical exam findings, and treatment response.

Billing considerations?

Ensure accurate coding to reflect the specific type of dysfunction and associated treatments.