Urology Coding Alert

Enterocele, rectocele, urethrocele, and cystocele codes will have 1-1 crosswalks.

If your urologist performs urogynecology and prolapse procedures, such as anterior colporrhaphies or paravaginal defect repairs, he may also perform a repair of an enterocele, rectocele, urethrocele, or cystocele during the procedures.

With ICD-9 you have just one code to report a vaginal enterocele (618.6, Vaginal enterocele congenital or acquired), one code for a urethrocele (618.03, Prolapse of vaginal walls without mention of uterine prolapse; urethrocele), and one code for a rectocele (618.04, Prolapse of vaginal walls without mention of uterine prolapse; rectocele).

For a cystocele (when the patient is not pregnant and without uterine prolapse), choose from the following codes:

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

ICD-10: Once ICD-10 is implemented on Oct. 1, 2013, you'll still have one code for enteroceles, one code for urethroceles, and one code for rectoceles. You'll use N81.5 (Vaginal enterocele) to report a vaginal enterocele, N81.0 (Urethrocele) for a urethrocele, and N81.6 (Rectocele) for a rectocele.

With regard to cystocele coding, when your diagnosis code system changes you'll choose from the following options:

• Code 618.01 will become N81.10 (Cystocele, unspecified) or N81.11 (Cystocele, midline).
• Code 618.02 will become N81.12 (Cystocele, lateral).

Physician documentation: Your urologist should already be documenting the type of prolapse the patient has, but ensure that is the case going forward. With the one-to-one crosswalk for the enterocele, rectocele, urethrocele, and cystocele codes, you probably won't need to make additional room on your superbill for these ICD-10 diagnostic codes.