Prolapse of vaginal vault after hysterectomy

This code describes the descent or dropping of the top portion of the vagina (vaginal cuff or apex) into the vaginal canal or beyond the introitus, occurring as a complication following a hysterectomy. It represents a type of pelvic organ prolapse specifically affecting the vaginal vault after the uterus has been surgically removed.

Assign this code when documentation clearly indicates a diagnosis of vaginal vault prolapse in a patient with a history of hysterectomy. This condition is often noted during gynecological examinations when the patient presents with symptoms such as a feeling of pressure, a bulge, or difficulty with urination or defecation.

• Ensure the medical record explicitly states "post-hysterectomy" or provides a history of hysterectomy to support the "after hysterectomy" specificity.
• Differentiate from other types of pelvic organ prolapse (e.g., cystocele, rectocele) that may coexist but are coded separately if distinct.
• 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 being managed.