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v1.0.0
ICD-10 Guide
DiagnosesRectocele

Rectocele

ICD-10 Coding for Rectocele(N81.6)

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

Diagnosis Overview

What is Rectocele?
Essential facts and insights about Rectocele

Key Clinical Considerations:

  • Bulging of the rectum into the posterior vaginal wall
  • Difficulty with bowel movements or incomplete evacuation
  • Pelvic pressure or discomfort

Clinical Information

Clinical Criteria & Documentation Requirements

  • Patient history of pelvic floor disorders
  • Detailed description of symptoms and their impact on daily life
  • Findings from pelvic examination, including size and extent of the rectocele

Coding Guidelines

Usage Guidelines & Examples

  • Follow guidelines for coding severity based on symptoms
  • Common errors include misclassifying the type of pelvic organ prolapse

Code Exclusions

Important Exclusions

  • Other types of pelvic organ prolapse (e.g., cystocele, uterine prolapse)
  • ICD codes for unrelated bowel disorders

Related ICD-10 Codes

Primary Codes
N81.2
Rectocele
Ancillary Codes
57267
Differential Codes
N81.5

Related CPT Codes

CPT codes will be available in a future update.

Specialty Focus

Primary Specialty

Gynecology

Specialty Applications

  • Women experiencing pelvic floor disorders
  • Gynecological and urological clinical 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

What are the documentation requirements?

Document the patient's symptoms, physical exam findings, and any imaging results.

What are the billing considerations?

Ensure accurate coding based on the severity and symptoms documented.