Isthmocele

This code describes an isthmocele, which is a defect or pouch-like indentation in the anterior uterine wall at the site of a previous cesarean section scar. It results from incomplete healing of the myometrial incision and can lead to various gynecological symptoms.

Use this code when documentation explicitly identifies an isthmocele or cesarean scar defect as the patient's diagnosis, particularly when it is causing symptoms such as abnormal uterine bleeding, chronic pelvic pain, or secondary infertility. This code applies when the isthmocele is the primary reason for the encounter and is not related to current pregnancy or postpartum care.

• Do not code this with O34.22 if the patient is currently pregnant and receiving maternal care for the isthmocele.
• Ensure documentation clearly distinguishes an isthmocele from other uterine anomalies or scar complications.
• Consider sequencing this code as the primary diagnosis if it is the main reason for the patient's visit and treatment.