The pelvic floor is a network of muscles, ligaments, and other tissues that hold up the pelvic organs such as the vagina, rectum, uterus, and bladder. If the pelvic floor becomes torn or weakens, the organs may shift, fall, or push against each other, causing problems. Common pelvic floor disorders include the following:

• fecal incontinence;

• urinary incontinence;

• constipation;

• pelvic pain;

• rectal pain;

• rectal prolapse; and

• vaginal prolapse.

Fecal incontinence (ICD-9-CM code 787.6) is the inability to control bowel movements. Common causes of fecal incontinence include injury during childbirth, other types of injuries to the anus or spinal cord, rectal prolapse, dementia, neurologic injury from diabetes, or tumors of the anus.

Urinary incontinence is the uncontrollable loss of urine. The code assignment will depend on the type of urinary incontinence and includes the following:

• Stress incontinence (female, 625.6; male, 788.32) is the uncontrollable loss of urine when there is an increase in abdominal pressure that may be caused by coughing, laughing, straining, sneezing, or lifting heavy objects.

• Urge incontinence (788.31) is the urgent desire to urinate followed by the uncontrollable loss of urine. Patients with urge incontinence cannot hold urine for any length of time once the need to urinate is sensed. Urgency of urination without incontinence is classified to code 788.63.

• Overflow incontinence (788.38) is the uncontrolled leakage of small amounts of urine from a full bladder.

• Mixed incontinence (788.33) is the combination of the different types of urinary incontinence.

Other codes for urinary incontinence include the following:

• 788.30, Urinary incontinence, unspecified;

• 788.34, Incontinence without sensory awareness;

• 788.35, Post-void dribbling;

• 788.36, Nocturnal enuresis;

• 788.37, Continuous leakage; and

• 788.39, Other urinary incontinence.

Constipation occurs when bowel movements become difficult or less frequent. Normal frequency of bowel movements varies widely from three times per day to three times per week. It is not normal to go longer than three days without a bowel movement. There are two main types of constipation:

• Slow transit constipation (564.01) is the delayed passage of bowel contents. Common causes of slow transit constipation include lack of fiber in diet and inadequate water intake.

• Outlet dysfunction constipation (564.02) is caused by poor muscle tone in the pelvic floor. It “results from difficulty evacuating the rectum secondary to failure to relax or paradoxical contraction of the striated pelvic floor muscles during defecation attempts” (AHA Coding Clinic for ICD-9-CM, 2001, fourth quarter, pages 45-46).

Unspecified constipation is classified to code 564.00 and includes a diagnosis of simple constipation. Code 564.09 identifies other constipation and includes the following:

• atonic constipation;

• drug-induced constipation when the correct drug is properly administered;

• neurogenic constipation; and

• spastic constipation.

Anal or rectal pain (569.42) is the discomfort or distress in the anal or rectal area.

Vaginal prolapse is the downward displacement of the vaginal walls. A code from category 618 will be assigned depending on the type and what organs are included with the vaginal prolapse.

Rectal prolapse (569.1) is the protrusion of the rectum through the anus. Rectal prolapse causes the rectum to turn inside out so the rectal lining is visible from the anus.

Pelvic pain is assigned to category 625 depending on the cause of the pain such as the following:

• Dyspareunia (625.0) is genital pain during sexual intercourse.

• Vaginismus (625.1) is an involuntary contraction of the lower vaginal muscles that prevents the penis from penetrating the vagina.

• Mittelschmerz (625.2) is lower abdominal pain on one side occurring at the time of ovulation.

• Dysmenorrhea (625.3) is abdominal pain caused from uterine cramps during a menstrual period.

Pelvic pain with unspecified cause is classified to code 625.9.

Coding and sequencing for pelvic floor disorders 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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