Cracking the Code

Complete VS Incomplete Uterine Prolapse

There are a couple steps coders should follow when they are coding prolapse of the vagina and/or the uterus. First, it is important to determine whether the condition involves the vaginal wall, the uterus, or both. Second, coders should determine whether the prolapse is complete or incomplete. A complete prolapse involves the uterus falling out of the vagina while an incomplete prolapse involves the uterus only partly sagging into the vagina. When a provider diagnoses a patient with first degree (stage I) or second degree (stage II) uterine prolapse, it is considered incomplete. When a provider has a final diagnosis of third degree (stage III) uterine prolapse, it is considered complete.

In some cases, a provider may diagnose a patient experiencing both anterior prolapse (cystocele) and uterine prolapse. Per coding guidance (Excludes 1 note), coders should NOT report the cystocele separately as it is included in the diagnosis code for the uterine prolapse. If documentation states a patient has the cystocele in a stage and the uterine prolapse in a different stage, then it is appropriate to report the diagnosis code for the stage of the uterine prolapse.

Q: A 69-year-old post-menopausal female was seen on an outpatient basis for uterine prolapse. Exam showed a grade 3 cystocele and grade 2 uterine prolapse.
A: N18.2, Incomplete uterovaginal prolapse
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