Ob-Gyn Coding Alert

You’ll have a new unspecified code to add to your coding options.

Cystocele refers to a fallen bladder. This occurs when the wall between the bladder and vagina weakens, and the bladder falls into the vagina. The patient feels discomfort and has problems emptying the bladder.

ICD-9-CM Codes: Currently, you should report this condition with:

• 618.01, Cystocele, midline
• 618.02, Cystocele, lateral

ICD-10-CM Codes: After October 1, 2015, you’ll change over to the following diagnoses:

• N81.10, Cystocele, unspecified
  
• N81.11, Cystocele, midline
  
• N81.12, Cystocele, lateral
  

When your coding system changes in 2015, your cystocele options expand to three codes. This means that if you have an unspecified cystocele, you will now have a specific coding option. Currently, you would code a cystocele “NOS” to 618.01. 

On the other hand, you have a direct one-to-one correlation between 618.02 to N81.12.

Documentation: If your physician documents a “paravaginal” cystocele, then you should report N81.12. 

Under the N81.1- category you’ll see the terms “cystocele with urethrocele” and “cystourethrocele,” so if your physician has documented these conditions, you would assign one of the N81.1- codes.

Here’s how you’ll find these codes in your Alphabetic Index:

Cystocele (-urethrocele)

- female N81.10
- - with prolapse of uterus —see Prolapse, uterus
- - lateral N81.12
- - midline N81.11
- - paravaginal N81.12

Cystourethrocele —see also Cystocele

- female N81.10
- - with uterine prolapse —see Prolapse, uterus
- - lateral N81.12
- - midline N81.11
- - paravaginal N81.12

Coding Tips: Under the N81.1- category, you’ll see the Excludes1 note that says “cystocele with prolapse of uterus (N81.2-N81.4).” That means that if the patient also has uterine prolapse, you would no longer report code N81.10-N18.12.