Coding for Pelvic Prolapse
For The Record
Vol. 18 No. 6 P. 40

Pelvic prolapse refers to any combination of vaginal, uterine, or bowel prolapse. A prolapse occurs when the woman’s pelvic floor muscles and/or ligaments relax, causing the organ to sag or sink. The most common causes of pelvic prolapse include the following:

• pregnancy;

• childbirth;

• obesity;

• heavy lifting;

• chronic constipation;

• poor nutrition;

• uterine fibroid;

• estrogen loss; and

• hysterectomy or other pelvic surgery.

Uterine Prolapse
Uterine prolapse is classified by degree:

• First degree: The cervix is visible when the perineum area is pressed.

• Second degree: The cervix is visible outside of the vaginal opening, while the uterine fundus remains inside.

• Third degree: The entire uterus is outside of the vaginal opening.

Uterine prolapse without mention of vaginal wall prolapse is classified to ICD-9-CM code 618.1. The degree of uterine prolapse does not affect code assignment. If the patient has a uterine prolapse with vaginal wall prolapse, then one of the following codes is assigned:

• 618.2 — uterovaginal prolapse, incomplete;

• 618.3 — uterovaginal prolapse, complete;

• 618.4 — uterovaginal prolapse, unspecified; or

• 618.89 — uterovaginal prolapse, other specified.

Other common types of pelvic prolapse include the following:

• Cystocele occurs when the wall between a woman’s bladder and her vagina weakens and stretches, allowing the bladder to bulge into the vagina. A cystocele without mention of uterine prolapse is classified to code 618.01 for midline cystocele or cystocele not otherwise specified or code 618.02 for lateral cystocele or paravaginal prolapse.

• Rectocele (618.04) occurs when the part of the rectum bulges into the vagina.

• Urethrocele (618.03) occurs when the urethra sags into the vagina.

• Perineocele (618.05) is a hernia between the rectum and vagina that protrudes into the vagina.

• Cystourethrocele (618.09) is an abnormal protrusion of the urethra and bladder into the vagina.

• Enterocele (618.6) occurs when the small intestine falls into the back of the vagina.

If any of the above types of vaginal wall prolapse are present with uterine prolapse, then a code from range 618.2 to 618.89 as mentioned above will be assigned instead.

If a patient experiences a vaginal wall prolapse (eg, cystocele, rectocele, urethrocele) following a hysterectomy, then code 618.5 is assigned.

Most often, the first symptom of prolapse is urinary incontinence. If urinary incontinence is present with pelvic prolapse, then one of the following codes should be assigned as a secondary diagnosis:

• 625.6, Female stress incontinence;

• 788.31, Urge incontinence;

• 788.33, Mixed incontinence;

• 788.34, Incontinence without sensory awareness;

• 788.35, Post-void dribbling;

• 788.36, Nocturnal enuresis;

• 788.37, Continuous leakage;

• 788.38, Overflow incontinence; or

• 788.39, Other urinary incontinence.

Treatment
Treatment for pelvic prolapse will depend on type and severity. The following are some common methods of treatment:

• estrogen therapy — estrogen helps to keep the pelvic muscles strong;

• pessary (96.18) — a plastic or rubber ring is inserted into the vagina to support the bladder by pushing it up and back into place;

• cystocele repair, also documented as anterior colporrhaphy (70.51);

• rectocele repair, also documented as posterior colporrhaphy (70.52);

• cystocele and rectocele repair/anterior and posterior colporrhaphy (70.50);

• enterocele repair (70.92);

• urethrocele repair (70.51);

• abdominal hysterectomy (68.3x-68.4);

• vaginal hysterectomy (68.5x);

• paraurethral suspension (59.6); and

• vesical neck suspension, also documented as modified Pereyra (59.79).

Coding and sequencing for pelvic prolapse are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Health Information Systems (800-367-2447), a supplier of coding and classification systems to nearly 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payors as the result of the misuse of this coding information.

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