Prolapse of vaginal vault after hysterectomy

This code describes the downward displacement or protrusion of the apex of the vagina following a hysterectomy. This condition occurs when the supporting structures of the vaginal cuff weaken, allowing the vaginal vault to descend into or outside the vaginal canal. It is a form of pelvic organ prolapse specifically occurring after the uterus has been surgically removed.

Use this code when documentation clearly indicates a diagnosis of vaginal vault prolapse in a patient who has previously undergone a hysterectomy. This diagnosis is typically made based on physical examination findings and patient symptoms such as a feeling of pressure, a bulge, or discomfort. The medical record should explicitly link the prolapse to the prior hysterectomy.

• Ensure documentation specifies "vaginal vault" prolapse and not other types of pelvic organ prolapse (e.g., cystocele, rectocele) unless also present and separately coded.
• Confirm a history of hysterectomy is present in the patient's record to support the "after hysterectomy" specificity.
• Consider sequencing this code as a primary diagnosis if it is the reason for the encounter, or as a secondary diagnosis if it is a co-morbidity or complication being managed.