Ob-Gyn Coding Alert

Question: I need help to make sure these are the correct diagnosis codes to use. My provider only listed 618.89, but the note states the patient has a rectocele and cystocele, so wouldn’t it be 618.4? On the exam the uterus is normal. Also, do we need documentation on how the pessary is cleaned?

Minnesota Subscriber

Answer: With the documentation you have indicated, she does not have uterine and vaginal wall prolapse, so the code you have proposed, 618.4 (Uterovaginal prolapse, unspecified) would not be correct. But neither would the code indicated by your provider be correct which indicates only “other specified genital prolapse.”  In this case, and based on the documentation, your codes for this visit should be 618.01 (Prolapse of vaginal walls without uterine prolapse, cystocele, midline) and 618.04 (Prolapse of vaginal walls without uterine prolapse, rectocele).

ICD-10: When we convert to ICD-10, the codes mentioned in this question will become:

• N81.89 — Other female genital prolapse

• N81.4 — Uterovaginal prolapse, unspecified

• N81.10 — Cystocele, unspecified

(Note: The ICD-9 code 618.01 includes cystocele NOS, which translates into N81.10 in ICD-10. If this provider has documented a midline cystocele instead, you would report N81.11 (Cystocele, midline) instead).

An E/M code (99201-99215, Office or other outpatient visit …) for cleaning does not require a description of how it was cleaned, but good clinical documentation should probably mention what was done in case an infection develops later and the patient decides it was due to the Pessary not being cleaned properly.