2025 ICD-10-CM code N81.2
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Diseases of the genitourinary system - Noninflammatory disorders of female genital tract (N80-N98) Diseases of the genitourinary system (N00-N99) Feed
Incomplete uterovaginal prolapse; the uterus descends into the vagina but does not protrude from the vaginal opening.
Modifiers may be applicable depending on the circumstances of the encounter and the specific procedures performed.
Medical necessity for treatment of incomplete uterovaginal prolapse is established based on the presence of bothersome symptoms such as pelvic pressure, heaviness, urinary or bowel dysfunction, or sexual dysfunction. The severity of the symptoms and the patient’s desire for intervention, guided by the clinical judgement of the treating physician, determines the need for treatment (surgical, pessary or other).
Gynecologist or other qualified healthcare professional responsible for diagnosis and management of uterovaginal prolapse. This might include pelvic examination, assessment of symptoms, imaging studies, and discussion of treatment options such as pessaries, surgery or conservative management.
- Diseases of the genitourinary system (N00-N99)
- N80-N98 (Noninflammatory disorders of the female genital tract)
In simple words: Incomplete prolapse of the uterus means the uterus has slipped down into the vagina, but it hasn't come out of the vagina.It's like the uterus is sagging or dropping a bit.
Incomplete uterovaginal prolapse is a condition where the uterus descends partially into the vagina but does not protrude externally.This is characterized by a sagging or displacement of the uterus within the vaginal canal. The severity can vary, and it's often categorized into stages based on the extent of descent.It is a non-inflammatory condition.
Example 1: A 60-year-old female patient presents with a feeling of pelvic pressure and heaviness, and a bulge noted during a pelvic exam consistent with an incomplete uterine prolapse. She is asymptomatic and chooses conservative management., A 45-year-old female patient reports urinary incontinence and difficulty with bowel movements.A pelvic exam reveals a Stage II incomplete uterovaginal prolapse. She opts for a pessary to manage symptoms., A 72-year-old female patient post-hysterectomy has a recurrence of pelvic organ prolapse, diagnosed as an incomplete uterovaginal prolapse (following previous surgery for a complete prolapse).She is considering surgical repair.
Complete history and physical examination, including a detailed description of the patient's symptoms (pelvic pressure, heaviness, urinary or bowel dysfunction).Findings from pelvic examination should be documented, including the extent of prolapse (stage). Supporting imaging studies such as pelvic ultrasound or MRI may be needed to confirm the diagnosis and guide treatment decisions.Documentation of any comorbidities that might influence treatment should be included.
** This code should be used only for incomplete uterovaginal prolapse.Complete prolapse is coded differently.Always confirm the stage and extent of prolapse based on clinical findings and documentation. The information provided is for informational purposes only and should not be considered medical advice. Always consult with qualified healthcare professionals for diagnosis and treatment options.
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- Specialties:Gynecology, Obstetrics
- Place of Service:Office, Hospital (Inpatient or Outpatient), Ambulatory Surgical Center