Uterine prolapse without mention of vaginal wall prolapse

This code represents the downward displacement of the uterus into the vaginal canal, occurring without concurrent prolapse of the anterior or posterior vaginal walls. It signifies a weakening of the pelvic floor support structures specifically affecting the uterus.

Apply this code when documentation clearly indicates uterine prolapse, such as "first-degree uterine prolapse" or "uterus prolapsed into the vagina," and there is no mention of cystocele or rectocele. This is appropriate for cases where only the uterus has descended.

• Do not use this code if any degree of vaginal wall prolapse (cystocele or rectocele) is also documented; a combination code would be more appropriate.
• Specify the degree of prolapse (e.g., first, second, third degree) if documented, though it does not change the code selection for ICD-9-CM.
• Ensure the physician's documentation explicitly states "uterine prolapse" or a similar phrase indicating uterine descent.