Ob-Gyn Coding Alert

Question: How should I code a patient who has a uterine prolapse but also has a cystocele and rectocele?

Missouri Subscriber

Answer: Unfortunately, this is an either/or situation from a diagnostic coding perspective. Carriers assume that if you use the code for uterovaginal prolapse, then this code infers that the patient has either a cystocele or rectocele present because that is what frequently happens when the vaginal walls prolapse.
 
So you have two codes to choose from in this case. If the uterus drops only partway into the vagina (also referred to as first-degree prolapse), you would report 618.2 (Uterovaginal prolapse, incomplete). If the uterus and cervix protrude out of the vagina, and the vagina becomes inverted (also referred to as a second- or third-degree prolapse), you would report 618.3 (Uterovaginal prolapse, complete).