The POP-Q system which was developed to assess the degree of prolapse of the pelvic organs was developed in 1996 to help standardize diagnosing, comparing, documenting and sharing clinical findings between providers. After the exam is completed, the provider should be indicating the degree of prolapse under impressions and whether that prolapse includes or excludes the uterus.
The numbers entered in the areas measured will determine the extent of the prolapse – in other words the provider is supposed to indicate the stage of the prolapse at the end of the exam. While a coder can review the exam elements, it is, in my opinion, the responsibility of the provider to specify the stage and location of the prolapse. Here is a (I hope) quick explanation of the exam.
The exam measures 6 defined points (Aa, Ba, C, D, Ap, Bp) in the vagina and they are used to record the extent of the descent or prolapse of the anterior vaginal wall, the vaginal apex, and the posterior vaginal wall. The positions of these six defined points are measured while the patient strains to see how close they come to the hymen (or hymenal ring). Points are defined as follows:
Aa is the closest part of anterior vaginal wall in relation to the hymen;
Ba is the farthest away part of the anterior vaginal wall to the hymen;
C is where the tip of cervix or the vaginal cuff (if the uterus has been removed) is to the hymen;
Ap and Bp represent the posterior vagina (closest and farthest away);
D the posterior fornix (which is only measured when there is a uterus).
Three additional measurements are taken to get a full description: the genital hiatus length (GH), perineal body length (PB), and total vaginal length (TVL). These 3 are measured separately and are not related to the hymen so the measurements in centimeters are actual measurements of the area. If the total vaginal length is positive, it means the vagina has not totally become prolapsed. A negative length implies the vaginal canal is outside of the body.
So how do they record these measurements? If the point being measured descends to the hymen it is measured as 0 cm, if it stays above the hymen it is measured in centimeters as a negative number, and if it descends below the hymen it is measured in centimeters as a positive number. For example, if point C (the cervix or vaginal cuff) remains 4 cm above the hymen during the exam it is recorded as −4 cm. If point C is 4 cm below the hymen during the exam it is recorded as +4 cm.
Staging a POP relies on identifying the lowest extent of any part of the six defined points; if any point reaches close to the hymenal ring (at least stage 2), the prolapse is usually symptomatic. Once all the measurements are recorded the provider would stage the prolapse as follows:
Stage 0: No prolapse is demonstrated (points Aa, Ba, C, D Ap, and Bp are all less than or equal to −3 cm).
Stage I: The most distal (farthest away) portion of the prolapse is more than 1 cm above the level of the hymen (points Aa, Ba, C, D, Ap, and Bp are all less than −1 cm).
Stage II: The most distal portion of the prolapse is between 1 cm above the hymen and 1 cm below the hymen (any of the points Aa, Ba, C, D, Ap, and Bp has a value between −1 cm and +1 cm).
Stage III: The most distal portion of the prolapse is more than 1 cm below the hymen, but not completely turned inside out meaning no value is greater than or equal to a total vaginal length of −2 cm. This would mean that any of the points Aa, Ba, C, D, Ap, Bp is greater than or equal to +2 and less than or equal to a total vaginal length of −3 cm)
Stage IV: Complete prolapse or prolapse to within 2 cm of the total vaginal length of the lower genital tract (any of the Points Ba, C, D, or Bp is greater than or equal to a total vaginal length of -2 cm).
However, you can also use the shortcut to determine what is going on by using the POP-Q tool (
https://pop-q.netlify.app/). On the tool, first pick the tab that indicates “with” or “without” uterus. Then enter your exam values from the note, then on the diagram, click on the assessment tab. This will show you what the prolapse looks like but will also tell you the stage.
But keep in mind that ICD-10 codes are chosen based on only a few factors: If the uterus is present, you need to know if the prolapse is complete (stage 3) or incomplete (stage 1 or 2). If the patient also has (singly or in combination) posterior wall (rectocele or enterocele) or anterior wall prolapse (cystocele, urethrocele) you do not report the individual codes for them as well, only the degree of uterovaginal prolapse indicated by the provider. If the uterus is absent, you report instead the individual codes for the type of anterior or posterior wall prolapse indicated by the provider.
So now to your specific example. In your example, we know that the patient does not have a uterus (there is no value listed for point D) and we also know that the posterior wall is at the hymen (with 0 values) so this could mean stage 2 posterior wall prolapse (N81.6) which may or may not be symptomatic for this patient. We also know that there are positive values for the anterior wall which means a stage 3 anterior wall prolapse (cystocele), and that the vaginal cuff is 4 cm above the hymen which means there is stage 2 vaginal vault prolapse (N99.3). But we do not know what type of cystocele (so you can only report N81.10) nor do we know if a ureterocele is present and this information can only be diagnosed by the provider. We also do not know if the posterior wall prolapse might also include an enterocele. In my opinion, there should be some provider education going on in your practice with regard to prolapse diagnosing or at the very least have a template that allows them to select the most specific codes at the end of the visit. For purposes of coding the first evaluation of the prolapse, it may not matter that this more specific information is missing from the record, but if surgery is performed or certain treatments initiated, the exact nature of the prolapse will need to be specified to avoid denials.
