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  6. 2024 ICD-10-CM Code N81.6

2024 ICD-10-CM Diagnosis Code N81.6

Rectocele

ICD-10-CM Code:
N81.6
ICD-10 Code for:
Rectocele
Is Billable?
Yes - Valid for Submission
Chronic Condition Indicator: [1]
Chronic
Code Navigator:

Code Classification

  • Diseases of the genitourinary system
    (N00–N99)
    • Noninflammatory disorders of female genital tract
      (N80-N98)
      • Female genital prolapse
        (N81)

N81.6 is a billable diagnosis code used to specify a medical diagnosis of rectocele. The code is valid during the current fiscal year for the submission of HIPAA-covered transactions from October 01, 2023 through September 30, 2024.

This code is applicable to female patients only. It is clinically and virtually impossible to use this code on a non-female patient.

Approximate Synonyms

The following clinical terms are approximate synonyms or lay terms that might be used to identify the correct diagnosis code:

  • Complete prolapse of posterior wall of vagina
  • Female rectocele co-occurrent with enterocele
  • Herniation of rectum into vagina
  • Herniation of rectum into vagina
  • Herniation of rectum into vagina
  • Herniation of rectum into vagina
  • Incomplete prolapse of posterior wall of vagina
  • Posterior vaginal wall prolapse
  • Prolapse of small intestine
  • Rectal prolapse
  • Rectocele affecting obstetric care
  • Rectocele affecting pregnancy
  • Rectocele in pregnancy, childbirth and puerperium
  • Vaginal enterocele

Clinical Classification

Clinical Information

  • Rectocele

    herniation of the rectum into the vagina.

  • Rectal Prolapse

    protrusion of the rectal mucous membrane through the anus. there are various degrees: incomplete with no displacement of the anal sphincter muscle; complete with displacement of the anal sphincter muscle; complete with no displacement of the anal sphincter muscle but with herniation of the bowel; and internal complete with rectosigmoid or upper rectum intussusception into the lower rectum.

  • Rectal Prolapse

    protrusion of the rectum through the anus.

Tabular List of Diseases and Injuries

The following annotation back-references are applicable to this diagnosis code. The Tabular List of Diseases and Injuries is a list of ICD-10-CM codes, organized "head to toe" into chapters and sections with coding notes and guidance for inclusions, exclusions, descriptions and more.


Inclusion Terms

Inclusion Terms
These terms are the conditions for which that code is to be used. The terms may be synonyms of the code title, or, in the case of "other specified" codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.
  • Prolapse of posterior vaginal wall

Use Additional Code

Use Additional Code
The “use additional code” indicates that a secondary code could be used to further specify the patient’s condition. This note is not mandatory and is only used if enough information is available to assign an additional code.
  • code for any associated fecal incontinence, if applicable R15

Type 1 Excludes

Type 1 Excludes
A type 1 excludes note is a pure excludes note. It means "NOT CODED HERE!" An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

Type 2 Excludes

Type 2 Excludes
A type 2 excludes note represents "Not included here". An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.

Index to Diseases and Injuries References

The following annotation back-references for this diagnosis code are found in the injuries and diseases index. The Index to Diseases and Injuries is an alphabetical listing of medical terms, with each term mapped to one or more ICD-10-CM code(s).

Code Edits

The Medicare Code Editor (MCE) detects and reports errors in the coding of claims data. The following ICD-10-CM Code Edits are applicable to this code:

  • Diagnoses for females only - The Medicare Code Editor detects inconsistencies between a patient’s sex and any diagnosis on the patient’s record, these edits apply to FEMALES only .

Convert N81.6 to ICD-9-CM

  • ICD-9-CM Code: 618.04 - Rectocele

Patient Education


Pelvic Floor Disorders

The pelvic floor is a group of muscles and other tissues that form a sling or hammock across the pelvis. In women, it holds the uterus, bladder, bowel, and other pelvic organs in place so that they can work properly. The pelvic floor can become weak or be injured. The main causes are pregnancy and childbirth. Other causes include being overweight, radiation treatment, surgery, and getting older.

Common symptoms include:

  • Feeling heaviness, fullness, pulling, or aching in the vagina. It gets worse by the end of the day or during a bowel movement.
  • Seeing or feeling a "bulge" or "something coming out" of the vagina
  • Having a hard time starting to urinate or emptying the bladder completely
  • Having frequent urinary tract infections
  • Leaking urine when you cough, laugh, or exercise
  • Feeling an urgent or frequent need to urinate
  • Feeling pain while urinating
  • Leaking stool or having a hard time controlling gas
  • Being constipated
  • Having a hard time making it to the bathroom in time

Your health care provider diagnoses the problem with a physical exam, a pelvic exam, or special tests. Treatments include special pelvic muscle exercises called Kegel exercises. A mechanical support device called a pessary helps some women. Surgery and medicines are other treatments.

NIH: National Institute of Child Health and Human Development


[Learn More in MedlinePlus]

Code History

  • FY 2024 - No Change, effective from 10/1/2023 through 9/30/2024
  • FY 2023 - No Change, effective from 10/1/2022 through 9/30/2023
  • FY 2022 - No Change, effective from 10/1/2021 through 9/30/2022
  • FY 2021 - No Change, effective from 10/1/2020 through 9/30/2021
  • FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020
  • FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
  • FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
  • FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
  • FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016. This was the first year ICD-10-CM was implemented into the HIPAA code set.

Footnotes

[1] Chronic - a chronic condition code indicates a condition lasting 12 months or longer and its effect on the patient based on one or both of the following criteria:

  • The condition results in the need for ongoing intervention with medical products,treatment, services, and special equipment
  • The condition places limitations on self-care, independent living, and social interactions.