Documenting and Coding Vaginal Prolapse – Symptoms and Treatment Options

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Vaginal prolapse is a condition which occurs when the network of muscles that support the organs in a woman’s pelvis gets weakened or fall out of their normal positions. This weakening allows the uterus, urethra, bladder, or rectum to droop down into the vagina. Generally, the network of muscles, ligaments and skin in and around a woman’s vagina (fascia) acts as a complex structure that holds the pelvic organs and tissues in place. Various parts of this support system may eventually weaken or break, causing a common condition called vaginal prolapse. If the pelvic floor muscles weaken enough, these organs can even protrude out of the vagina. One of the main causes of this condition is childbirth – which can easily stretch and weaken these muscles, especially for a woman who had a difficult delivery. Aging and the loss of estrogen during menopause can also weaken these muscles. Other related causes include – pressure from excess weight, constant coughing (from chronic lung disease), lifting heavy objects and chronic constipation. Without adequate medical treatment or surgery, these structures may eventually prolapse farther and farther into the vagina or even through the vaginal opening. Obstetrician – gynecologists treating patients with this condition must know the right ICD-10 codes to report the condition correctly. Utilizing physician billing services can ensure timely, error-free claim submission for appropriate reimbursement.

This vaginal condition can occur in women of any age group. However, it often affects postmenopausal women who have undergone one or more vaginal deliveries or hysterectomy. Other risk factors of vaginal prolapse include advanced age, abnormalities of the connective tissue, obesity, smoking, dysfunction of the nerves and tissues, and strenuous physical activity.

Types of Vaginal Prolapse and Related Symptoms

Vaginal Prolapse involves four different types –

  • Anterior vaginal prolapse (cystocele or urethrocele) – occurs when the bladder falls down into the vagina.
  • Posterior vaginal prolapse (rectocele) – occurs when the wall separating the rectum from the vagina weakens, which causes the rectum to bulge into the vagina.
  • Uterine prolapse – occurs when the uterus droops down into the vagina.
  • Apical prolapse (vaginal vault prolapse) – occurs when the cervix or upper part of the vagina falls down into the vagina.

Generally, women do not experience any specific symptoms from vaginal prolapse. However, in extreme cases, they may experience symptoms that may depend on the type of vaginal prolapse that has occurred. One of the most common symptoms associated with this condition is the sensation that tissues or structures in the vagina are out of place. Most women describe the feeling as “something coming down” or as a dragging sensation. This may involve a protrusion or pressure in the area of the sensation. In most cases, the more advanced the prolapse, the more severe will be the associated symptoms. Other additional symptoms include –

  • A feeling of heaviness or pressure in the vagina
  • A lump at the opening of the vagina
  • Urinary stress incontinence
  • Pain that increases during long periods of standing
  • Pain during sex
  • Frequent bladder infections
  • Difficulty emptying bowel/bladder
  • Achy pain in the lower back area (that gets better when you lie down)
  • Abnormal bleeding from the vagina

How to Diagnose and Treat Vaginal Problem?

Diagnosis of vaginal prolapse begins with a detailed pelvic examination. Gynecologistsmay examine in detail each section of the vagina separately to determine the type and extent of the prolapse, in order to decide the most appropriate type of treatment. He/she may test the strength of the pelvic floor, the sphincter muscles, and other muscles and ligaments that support the vaginal walls, uterus, rectum, urethra, and bladder. As many women with vaginal prolapse also experience urinary incontinence, several other tests like bladder function tests, Q-tip test and pelvic floor strength test can further evaluate the anatomy and function of the pelvic floor. In addition, other imaging tests like pelvic floor MRI, pelvic Ultrasound CT scan (of abdomen and pelvis) and cystourethroscopy will also be done to identify problems with the pelvic organs.

Treatment for this condition involves a combination of conservative and non-conservative treatment options. However, the type of treatment that is appropriate to treat a vaginal prolapse depends on factors like the causes and severity of the prolapse, whether the woman is sexually active, woman’s age and overall medical status and her desire for future childbearing. Conservative treatment options include – pelvic floor exercises like Kegels (which strengthen the muscles that support the vagina, bladder), Pessary (a small device made of soft plastic or rubber – placed within the vagina for support) and activity modifications like avoiding heavy lifting or straining. In addition, losing excess weight can take some of the pressure off from the bladder or other pelvic organs. If any of the above conservative treatment options do not give the desired results, surgery to put the pelvic organs back in place will be considered as a last option. The surgery can be done through the vagina or through small incisions (laparoscopically) in your abdomen.

ICD-10 Coding

The diagnostic tests and treatment procedures for vaginal prolapse must be correctly documented using the right codes. An experienced medical billing company can help physicians report the correct billing codes. ICD-10 codes for vaginal prolapse come under category N81.

N81 – Female genital prolapse

  • N81.0 – Urethrocele
  • N81.1 – Cystocele
    • N81.10 – Cystocele, unspecified
    • N81.11 – Cystocele, midline
    • N81.12 – Cystocele, lateral
  • N81.2 – Incomplete uterovaginal prolapse
  • N81.3 – Complete uterovaginal prolapse
  • N81.4 – Uterovaginal prolapse, unspecified
  • N81.5 – Vaginal enterocele
  • N81.6 – Rectocele
  • N81.8 – Other female genital prolapse
    • N81.81 – Perineocele
    • N81.82 – Incompetence or weakening of pubocervical tissue
    • N81.83 – Incompetence or weakening of rectovaginal tissue
    • N81.84 – Pelvic muscle wasting
    • N81.85 – Cervical stump prolapse
    • N81.89 – Other female genital prolapse
  • N81.9 – Female genital prolapse, unspecified

Woman who experience any specific symptoms of vaginal prolapse (including a feeling of fullness in the lower belly or a bulge in the vagina), must visit a gynecologist for a detailed examination. Even though the condition is not so dangerous, it can have a negative effect on the quality of life. Women at risk for vaginal prolapse (including those who have had corrective surgery) should try to avoid heavy lifting or any other activity that increases pressure within the abdominal cavity. As obesity can put extra stress on the muscles and ligaments within the pelvis and vagina, it is important to reduce body weight to prevent this condition from developing or recurring.

Medical billing and coding for vaginal prolapse can be challenging, as there are several codes associated with the condition. By outsourcing these tasks to a reliable obstetrics and gynecology medical coding company (that offers the services of AAPC-certified coding specialists), healthcare practices can ensure correct and timely medical billing and claims submission.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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