Wiki Pelvic floor dysfunction - ICD 10 code

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Miko24

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I am wondering about the dx code for Pelvic Floor Dysfunction. M99.05 or M62.81 or something else entirely.

Thank you
 
It's hard to say outside the context of the rest of the documentation, but I don't believe you can get to either of those codes just from 'pelvic floor dysfunction'. M99.05 would require documentation that the dysfunction is either 'somatic' or 'segmental'. M62.81 isn't supported at all, in my opinion. For a female patient, you may be able to use N94.9 for a disease of the pelvis NOS. Or, if your provider hasn't been more specific than this, you may need to query them or else use codes that describe the specific symptoms.
 
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Pelvic floor dysfunction can be caused by a number of specific conditions. I believe we can code that instead. For example, we will code rectocele and incomplete rectal emptying (N81.6 & R15.0).

REASON FOR EXAM:​

PELVIC FLOOR DYSFUNCTION~

EXAM:​

DEFECOGRAM

INDICATION:​

Pelvic floor dysfunction

COMPARISON:​

Pelvic floor MRI

TECHNIQUE:​

Standard fluoroscopic defecography.

FLUORO TIME:​

0.8 minutes

VIEWS:​

6 fluoroscopic Ron's

FINDINGS:​

Normal positioning of the rectum at rest and on Kegel maneuver.

Posterior filling defect seen on rest images significantly decreased following evacuation favoring stool.

There was incomplete rectal evacuation. There is mucosal infolding of the lower one third of the rectum. Small anterior rectocele is not as pronounced as it was on the MRI.

IMPRESSION:​

Mucosal infolding of the lower one third of the rectum with incomplete rectal emptying. Anterior rectocele not as pronounced as it was on the MRI.
 
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