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ICD-10 Guide
ICD-10 CodesN85.4

N85.4

Billable

Malposition of uterus

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

Code Description

ICD-10 N85.4 is a billable code used to indicate a diagnosis of malposition of uterus.

Key Diagnostic Point:

Malposition of the uterus refers to abnormal positioning of the uterus within the pelvic cavity. This condition can manifest as a retroverted (tilted backward), anteverted (tilted forward), or laterally displaced uterus. While many women with malposition may be asymptomatic, some may experience symptoms such as pelvic pain, dyspareunia (painful intercourse), or complications during pregnancy and childbirth. The malposition can be caused by various factors, including anatomical variations, previous surgeries, or conditions such as endometriosis or pelvic inflammatory disease. Diagnosis typically involves a pelvic examination and imaging studies such as ultrasound or MRI to assess the position and structure of the uterus. Treatment options may vary based on symptoms and can include physical therapy, surgical intervention, or monitoring. Understanding the implications of uterine malposition is crucial for managing reproductive health and addressing any associated complications.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in symptoms and presentation among patients
  • Need for imaging studies for accurate diagnosis
  • Potential overlap with other gynecological conditions
  • Documentation of patient history and physical examination findings

Audit Risk Factors

  • Inadequate documentation of symptoms and clinical findings
  • Failure to include imaging results in the medical record
  • Misclassification of malposition as a more severe condition
  • Lack of follow-up documentation for treatment outcomes

Specialty Focus

Medical Specialties

Obstetrics and Gynecology

Documentation Requirements

Detailed patient history, physical examination findings, imaging results, and treatment plans.

Common Clinical Scenarios

Patients presenting with pelvic pain, infertility evaluations, or complications during pregnancy.

Billing Considerations

Ensure that all relevant symptoms and diagnostic tests are documented to support the diagnosis.

Radiology

Documentation Requirements

Clear imaging reports indicating the position of the uterus and any associated abnormalities.

Common Clinical Scenarios

Imaging studies performed for pelvic pain or abnormal findings during routine examinations.

Billing Considerations

Radiologists should provide comprehensive reports that correlate imaging findings with clinical symptoms.

Coding Guidelines

Inclusion Criteria

Use N85.4 When
  • According to ICD
  • 10 guidelines, N85
  • 4 should be used when there is clear documentation of uterine malposition
  • It is important to ensure that the condition is not due to inflammatory processes or other specified disorders

Exclusion Criteria

Do NOT use N85.4 When
  • Exclusion criteria include conditions like uterine prolapse or neoplasms

Related ICD-10 Codes

Related CPT Codes

58150CPT Code

Total abdominal hysterectomy

Clinical Scenario

Performed in cases of severe malposition causing complications.

Documentation Requirements

Operative report detailing the indication for surgery and findings.

Specialty Considerations

Obstetricians should ensure that the reason for surgery is clearly linked to the malposition.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of uterine malposition, improving the accuracy of data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of uterine malposition, improving the accuracy of data collection and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

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 uterine malposition?

Common symptoms include pelvic pain, dyspareunia, and complications during pregnancy. However, many women may be asymptomatic.