Pelvic Pain ICD-10: Clinical Documentation and Care Planning

Pelvic pain is a common reason individuals seek outpatient rehabilitation and women’s health services. Because pelvic discomfort may stem from musculoskeletal, gynecologic, gastrointestinal, or urologic factors, selecting the correct pelvic pain ICD-10 code supports more accurate documentation, reimbursement, and continuity of care. A precise code helps reflect the complexity of the condition and aligns the treatment plan with the full clinical presentation.

This article outlines the most frequently used pelvic pain ICD-10 codes, documentation points that support accurate coding, patterns often seen in women’s health, an example of how a clinician may apply codes during an evaluation, and how standardized questionnaires can contribute to assessment and outcomes tracking.

Common pelvic pain ICD-10 codes

Pelvic pain can require multiple ICD-10 options depending on symptom type, location, and contributing diagnoses. Frequently used codes include:¹

R10.2 — Pelvic and perineal pain

This is the primary ICD-10 code used for lower pelvic or perineal discomfort, especially when the specific etiology has not yet been confirmed.

R10.30 — Lower abdominal pain, unspecified

Lower abdominal discomfort below the umbilicus may relate to abdominal wall or pelvic floor sensitivity and is used when symptoms are present but not tied to a more specific cause.

N94.6 — Dysmenorrhea, unspecified

Menstrual-related pelvic discomfort varies widely; this code is used when menstrual pain is present without a confirmed underlying diagnosis.

N94.81 — Dyspareunia

Pain during intercourse often appears in women’s health evaluations and may relate to pelvic floor tension, hormonal changes, childbirth recovery, or scar sensitivity.

N94.89 — Other specified conditions associated with female genital organs and menstrual cycle

This category applies when symptoms involve the menstrual cycle or gynecologic function but do not fit other specific codes.

N80.9 — Endometriosis, unspecified

Endometriosis is a leading cause of chronic pelvic pain and is frequently associated with multidisciplinary care and pelvic floor interventions.

Related codes are sometimes paired with pelvic pain ICD-10 codes

Secondary codes may accompany R10.2 to capture contributing factors:

• M62.89 — Other muscle disorders (commonly applied to pelvic floor muscle tension)

• R10.9 — Unspecified abdominal pain

• G89.29 — Other chronic pain

ICD-10 Codes List PDF

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Documentation considerations when selecting pelvic pain ICD-10 codes

Clear, precise documentation helps support pelvic pain ICD-10 code selection and demonstrate medical necessity throughout the episode of care. Key elements include:²

• Symptom location and pattern: document whether pain is suprapubic, perineal, unilateral, pressure-induced, or diffuse. These details help differentiate between codes such as R10.2 and R10.30.

• Duration of symptoms: note whether symptoms are new, persistent, cyclical, or triggered by specific activities.

• Suspected or confirmed etiology: pelvic pain may relate to pelvic floor tension, pregnancy or postpartum changes, bladder or bowel dysfunction, hormonal shifts, or gynecologic diagnoses.

• Functional impact: describe how symptoms affect sitting, movement, work tasks, sexual function, bladder or bowel habits, and daily activities. This supports the clinical rationale for treatment.

• Secondary conditions and contributing factors: constipation, urinary urgency, postpartum trauma, and abnormal muscle tone may shape coding decisions and influence the plan of care.

Patterns seen in pelvic pain presentations in women’s health

Pelvic pain often follows predictable patterns across different life stages. Recognizing these patterns can help clinicians select accurate ICD-10 codes and ensure documentation aligns with evaluation findings.³

Pregnancy-related pelvic girdle pain

Changes in joint mobility, abdominal support, and ligament tension may cause discomfort during pregnancy. When symptoms are clearly pregnancy-related, O26.891—Pain in Pelvis, pregnancy may be appropriate.

Postpartum pelvic pain

Birth-related trauma, scar sensitivity, pelvic floor tension, and joint irritation may contribute to postpartum discomfort. O90.89—Other Complications of the Puerperium can apply when symptoms relate to postpartum changes.

Pelvic floor muscle overactivity

Pelvic floor tension or dyscoordination is common in pelvic health evaluations. When these findings influence symptoms, pairing M62.89 with R10.2 helps reflect both pain and musculoskeletal contributors.

Gynecologic-related presentations

Chronic pelvic pain related to endometriosis, vulvodynia, or hormonally influenced discomfort may require codes such as N80.9 or other gynecologic-specific options.

Bladder and bowel contributors

Constipation, urinary urgency, or incomplete emptying can amplify pelvic pain. Secondary ICD-10 codes may clarify how these factors contribute to overall symptoms.

Example: Applying ICD-10 codes during a pelvic pain evaluation

Accurate ICD-10 coding depends on translating the patient’s symptoms and examination findings into a clear diagnostic picture. The case below illustrates how clinicians combine pain location, duration, contributing factors, and functional impact to select the most appropriate codes.

Case example

A 35-year-old individual presents with a six-month history of suprapubic and perineal pain that worsens with sitting and intercourse. During the examination, the clinician identifies elevated pelvic floor muscle tension and limited relaxation, with no confirmed gynecologic diagnosis at the time of evaluation. These symptoms are affecting the patient’s ability to sit for work, participate in physical activity, and tolerate prolonged positions, contributing to reduced quality of life.

Coding application

Based on the evaluation, the clinician selects:

• Primary code: R10.2 — Pelvic and perineal pain. 

  • Captures the patient’s primary complaint and overall pain presentation.

• Secondary code: M62.89 — Other muscle disorders.

  • Applied due to examination findings indicating pelvic floor overactivity.

• Secondary code (if applicable): N94.81 — Dyspareunia

  • Included when sexual pain is consistently present and documented through clinical assessment.

Documentation emphasis

Documentation highlights the pain location, duration, aggravating factors, functional limitations, and pelvic floor findings. The plan of care includes pelvic floor muscle retraining, manual techniques within scope, biofeedback, graded activity progression, and coordination with gynecology as needed.

Using questionnaires and outcome measures with pelvic pain ICD-10 codes

Standardized questionnaires help quantify symptoms, identify contributing factors, and support consistent progress tracking. They can strengthen the rationale for ICD-10 selection and support organizational outcomes reporting.

Common tools include:

• Pelvic Floor Distress Inventory (PFDI-20)

• Pelvic Pain and Urgency/Frequency (PUF) Questionnaire

• Female Sexual Function Index (FSFI)

• PROMIS Pain Interference or Physical Function

• Pain Catastrophizing Scale (PCS)

Example of questionnaire use

During intake, a clinician administers the PFDI-20. The patient reports high symptom scores related to pelvic pressure, bladder discomfort, and pain with sitting. These findings support the use of pelvic pain ICD-10 codes such as R10.2 and related secondary codes while helping tailor the treatment plan.

How ICD-10 codes guide the plan of care

Accurate ICD-10 coding does more than fulfill administrative requirements—it directly shapes how clinicians design, progress, and coordinate care. When codes reflect the true drivers of pelvic pain, they support a more targeted and collaborative treatment approach.

Clarifying treatment priorities

Well-chosen codes help clinicians focus intervention planning on the primary source of symptoms.

• R10.2 may guide early emphasis on pain modulation, gentle mobility, and pelvic floor assessment.

• M62.89 supports addressing muscle tension, neuromuscular re-education, and biofeedback.

• N80.9 may indicate the need for pain pacing strategies or coordination with gynecology.

Supporting interdisciplinary communication

Accurate codes help gynecology, urology, gastroenterology, obstetrics, and pelvic rehab providers align around the same clinical picture.

Justifying treatment progression

As codes reflect underlying contributors—such as pelvic floor overactivity, menstrual-related discomfort, or bladder/bowel influences—they clarify why certain interventions are prioritized.

Indicating when referral or co-management may be needed

Specific codes can highlight when symptoms extend beyond the scope of musculoskeletal care and require gynecologic, urologic, or GI consultation.

Improving continuity across episodes of care

As symptoms evolve and codes are updated, clinicians create a clearer picture of the patient’s trajectory across their care journey.

Improving clarity and supporting women’s health programs

As clinicians apply pelvic pain ICD-10 codes to document symptoms, contributing factors, and functional impact, many patients also benefit from structured support between visits. Medbridge’s Women’s Health Pathways were designed to complement this clinical decision-making by extending evidence-based care into daily life—helping patients stay engaged, build confidence, and progress toward meaningful recovery.

Pathways offer guided education, pelvic floor and core training, and symptom-specific digital care plans that directly align with the most common contributors captured through pelvic pain ICD-10 coding, including:

• pregnancy-related musculoskeletal pain

• postpartum pelvic floor dysfunction

• urinary incontinence

• menopause-related changes

By reinforcing key concepts between visits and providing daily guidance, Pathways helps patients maintain momentum, improve adherence, and participate more actively in their rehabilitation—critical drivers of successful pelvic health outcomes.

Accurate pelvic pain ICD-10 coding also gives organizations clearer insight into population trends, helping them identify care gaps, forecast service needs, and prioritize access to conservative women’s health programs at scale.

By integrating precise ICD-10 documentation with structured digital pathways, providers can deliver timely, guideline-aligned pelvic health care, reduce delays, expand access, and support women across the lifespan—without increasing clinical burden. Together, these tools help ensure that more women receive the comprehensive, high-quality pelvic health support they deserve.

References

1. Centers for Disease Control and Prevention. (2022). ICD-10-CM tabular list of diseases and injuries: FY 2022 (October 1, 2021 – September 30, 2022). U.S. Department of Health & Human Services. https://ftp.cdc.gov/pub/health_statistics/nchs/publications/ICD10CM/2022/icd10cm-tabular-2022-April-1.pdf

2. Centers for Medicare & Medicaid Services. (2024). FY 2024 ICD-10-CM official coding guidelines (Updated 02/01/2024). U.S. Department of Health & Human Services. https://www.cms.gov/files/document/fy-2024-icd-10-cm-coding-guidelines-updated-02/01/2024.pdf

3. National Institute of Child Health and Human Development. (n.d.). Pelvic pain. National Institutes of Health. https://www.nichd.nih.gov/health/topics/pelvicpain