ICD-10-CM Code N81.6

Rectocele

Version 2020 Billable Code Diagnoses For Females Only

Valid for Submission

N81.6 is a billable code used to specify a medical diagnosis of rectocele. The code is valid for the year 2020 for the submission of HIPAA-covered transactions. The ICD-10-CM code N81.6 might also be used to specify conditions or terms like complete prolapse of posterior wall of vagina, female proctocele without uterine prolapse, female proctocele without uterine prolapse, female rectocele co-occurrent with enterocele, herniation of rectum into vagina, herniation of rectum into vagina, etc

The code N81.6 is applicable to female patients only. It is clinically and virtually impossible to use this code on a non-female patient.

ICD-10:N81.6
Short Description:Rectocele
Long Description:Rectocele

Tabular List of Diseases and Injuries

The Tabular List of Diseases and Injuries is a list of ICD-10 codes, organized "head to toe" into chapters and sections with guidance for inclusions, exclusions, descriptions and more. The following references are applicable to the code N81.6:

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 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

The Index to Diseases and Injuries is an alphabetical listing of medical terms, with each term mapped to one or more ICD-10 code(s). The following references for the code N81.6 are found in the index:


Code Edits

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

  • Diagnoses for females only - Medicare Code Editor detects inconsistencies between a patient’s sex and any diagnosis on the patient’s record, this code applies to FEMALES only .

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 proctocele without uterine prolapse
  • Female proctocele without uterine prolapse
  • Female rectocele co-occurrent with enterocele
  • 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
  • Rectal prolapse
  • Rectocele affecting obstetric care
  • Rectocele affecting pregnancy
  • Rectocele complicating antenatal care - baby not yet delivered
  • Rectocele in pregnancy, childbirth and the puerperium
  • Vaginal enterocele

Clinical Information

  • RECTOCELE-. herniation of the rectum into the vagina.

Diagnostic Related Groups

The ICD-10 code N81.6 is grouped in the following groups for version MS-DRG V37.0 What are Diagnostic Related Groups?
The Diagnostic Related Groups (DRGs) are a patient classification scheme which provides a means of relating the type of patients a hospital treats. The DRGs divides all possible principal diagnoses into mutually exclusive principal diagnosis areas referred to as Major Diagnostic Categories (MDC).
applicable from 10/01/2019 through 09/30/2020.

  • 742 - UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC
  • 743 - UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC

Convert N81.6 to ICD-9

Code Classification

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

Code History

  • FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016
    (First year ICD-10-CM implemented into the HIPAA code set)
  • FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
  • FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
  • FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
  • FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020

Information for Patients


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


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