2025 ICD-10-CM code N81.4
Uterovaginal prolapse, unspecified.Prolapse of uterus NOS.
Medical necessity for treatment is established based on the severity of the prolapse, the presence of bothersome symptoms, and the impact on the patient's daily activities.Treatment aims to alleviate symptoms, improve pelvic organ support, and enhance the patient's quality of life.
Diagnosis and management of this condition falls under the purview of gynecologists and urogynecologists. They are responsible for conducting a thorough pelvic examination to assess the degree of the prolapse. Based on their assessment and factoring in other issues such as age, overall health, and desire for future childbearing, they decide on the most appropriate treatment plan. This may involve non-surgical options like pelvic floor exercises or the use of a pessary, or surgical interventions to repair the prolapse and reinforce pelvic floor support.
In simple words: The uterus and vagina have slipped down from their usual place.This is called a prolapse.
Uterovaginal prolapse is a condition where both the uterus and vagina descend lower than their normal position in the pelvis. This occurs when the pelvic floor muscles and ligaments that support these organs weaken, allowing them to bulge or protrude into or out of the vagina.This specific code indicates that the prolapse is not further specified as incomplete or complete.
Example 1: A 55-year-old postmenopausal woman presents complaining of a feeling of pelvic pressure and a bulge protruding from her vagina. Upon examination, the physician diagnoses her with a uterovaginal prolapse., A 70-year-old woman with a history of multiple vaginal deliveries experiences difficulty with urination and bowel movements. A pelvic exam reveals uterovaginal prolapse., A 40-year-old woman with a history of chronic constipation and obesity presents with lower back pain and discomfort during intercourse. A physical examination reveals uterovaginal prolapse.
Documentation should include details of the pelvic exam, including the degree of prolapse (e.g., stage of prolapse based on POP-Q system), associated symptoms (e.g., pelvic pressure, urinary or fecal incontinence, sexual dysfunction), and impact on the patient's quality of life.Any prior treatments or relevant medical history, like previous pregnancies or pelvic surgeries, should also be documented.
- Specialties:Gynecology, Urogynecology
- Place of Service:Office, Outpatient Hospital