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2025 ICD-10-CM code N81.3

Complete uterovaginal prolapse, also known as procidentia, is a third-degree uterine prolapse.

Refer to the official ICD-10-CM guidelines for proper coding and sequencing of diagnoses.N81.3 should be the principal diagnosis if it is the reason for the encounter.

No modifiers apply to N81.3.

Medical necessity for treatment of complete uterovaginal prolapse is established based on the severity of symptoms impacting quality of life, such as pelvic pressure, pain, urinary or bowel dysfunction, and sexual dysfunction.The documentation must support the clinical indication for treatment.

Diagnosis and management of complete uterovaginal prolapse, including examination, evaluation of symptoms, and treatment planning (surgical or non-surgical). This may involve consultation with other specialists depending on the complexity of the case.

IMPORTANT N81.3 is inclusive of cystocele and rectocele.Other codes, such as those specifying the degree of prolapse (e.g., incomplete prolapse N81.2),or prolapse of specific structures (e.g., urethrocele N81.0) should not be used in conjunction with N81.3.For prolapse following hysterectomy, use N99.3. Codes for complications of pregnancy, childbirth, or puerperium (O00-O9A) should not be used.

In simple words: Complete uterovaginal prolapse means the uterus and vagina have dropped down and are sticking out of the vaginal opening. This is a severe type of prolapse.

N81.3, Complete uterovaginal prolapse, refers to the complete descent of the uterus and vagina, extending beyond the vaginal opening.This is considered a third-degree prolapse.It involves the prolapse of the cervix, uterus, and vaginal walls.The condition may include associated conditions such as cystocele (bladder prolapse) and rectocele (rectal prolapse), but N81.3 is an inclusive code that encompasses these.

Example 1: A 70-year-old woman presents with a history of pelvic pressure, urinary incontinence, and constipation. Physical examination reveals a complete prolapse of the uterus and vagina.N81.3 is coded., A 65-year-old woman who underwent a hysterectomy several years ago presents with a prolapse of the vaginal vault.The physician assesses this as related to the prior surgery, and codes N99.3., A 55-year-old woman presents with symptoms suggestive of uterine prolapse, which is confirmed on examination. However, the extent of the prolapse is determined as not complete, and N81.2 (incomplete prolapse) is coded.

Complete history and physical examination findings, including the degree and extent of the prolapse (including involvement of the bladder or rectum), imaging studies (if performed), and documentation of any related symptoms.

** This code represents a severe form of female genital prolapse.Accurate assessment of the prolapse's extent is crucial for proper coding.Always review the official ICD-10-CM coding guidelines for the most up-to-date information.If there are any complicating factors, such as a concomitant infection or other medical conditions, these should be appropriately coded in addition to N81.3.

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