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ICD-10 Guide
ICD-10 CodesQ51.1

Q51.1

Billable

Doubling of uterus with doubling of cervix and vagina

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 Q51.1 is a billable code used to indicate a diagnosis of doubling of uterus with doubling of cervix and vagina.

Key Diagnostic Point:

Doubling of the uterus, cervix, and vagina is a rare congenital malformation characterized by the presence of two uteri, two cervices, and two vaginas. This condition arises from abnormal development during embryogenesis, specifically during the fusion of the Müllerian ducts, which typically form the female reproductive tract. The presence of this duplication can lead to various clinical implications, including complications during pregnancy, menstrual irregularities, and potential challenges in reproductive health. Patients may present with symptoms such as pelvic pain, abnormal bleeding, or difficulties in conception. Diagnosis is often made through imaging studies such as ultrasound or MRI, which can visualize the anatomical anomalies. Management may involve a multidisciplinary approach, including gynecological, obstetric, and sometimes surgical interventions, depending on the severity of the condition and associated symptoms.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and symptoms among patients
  • Need for detailed imaging studies for accurate diagnosis
  • Potential for associated anomalies in other organ systems
  • Differentiation from other uterine anomalies (e.g., septate uterus)

Audit Risk Factors

  • Inadequate documentation of clinical findings
  • Failure to include imaging results in the medical record
  • Misclassification of the condition with similar codes
  • Lack of clear treatment plans or follow-up documentation

Specialty Focus

Medical Specialties

Pediatrics

Documentation Requirements

Pediatric documentation should include growth and development assessments, family history of congenital anomalies, and any associated symptoms or complications.

Common Clinical Scenarios

Common scenarios include evaluation of newborns with ambiguous genitalia or referral for further assessment of congenital anomalies detected during routine examinations.

Billing Considerations

Accurate coding requires careful attention to the patient's age, developmental milestones, and any interventions performed.

Genetics

Documentation Requirements

Genetic documentation should include family history, genetic testing results, and any syndromic associations with the congenital condition.

Common Clinical Scenarios

Genetic counseling sessions for families with a history of congenital malformations or when a child presents with multiple anomalies.

Billing Considerations

Consideration of chromosomal abnormalities that may coexist with congenital malformations is crucial for accurate coding.

Coding Guidelines

Inclusion Criteria

Use Q51.1 When
  • According to the official coding guidelines, congenital malformations should be coded based on the specific anatomical and clinical findings
  • Documentation must support the diagnosis and any associated conditions

Exclusion Criteria

Do NOT use Q51.1 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

58150CPT Code

Total abdominal hysterectomy

Clinical Scenario

Performed in cases of severe uterine malformations causing significant symptoms.

Documentation Requirements

Operative report detailing the procedure and indications for surgery.

Specialty Considerations

Gynecological specialists should ensure accurate coding based on the surgical findings.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of congenital malformations, improving the accuracy of data collection and reimbursement processes. Q51.1 provides a clear classification for a rare condition that may have been inadequately captured in ICD-9.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of congenital malformations, improving the accuracy of data collection and reimbursement processes. Q51.1 provides a clear classification for a rare condition that may have been inadequately captured in ICD-9.

Reimbursement & Billing Impact

reimbursement processes. Q51.1 provides a clear classification for a rare condition that may have been inadequately captured in ICD-9.

Resources

Clinical References

  • •
    Congenital Anomalies: A Guide for Clinicians

Coding & Billing References

  • •
    Congenital Anomalies: A Guide for Clinicians

Frequently Asked Questions

What are the implications of a double uterus on pregnancy?

A double uterus can lead to complications such as preterm labor, miscarriage, and abnormal fetal positioning. Close monitoring during pregnancy is essential to manage these risks.