Wiki 3rd degree tear at delivery

Hi. I am a new coder but here are my suggestions: you can search in this Forum your question by typing in the Search box; you will find lots of information. Below I kept the copy from ACOG website. Also, if a different MD (other than a Delivery MD) repairs 3rd laceration, yes, you can bill for it separately. If the same MD who does a delivery and a repair, you can add a modifier -22. Pls see below.​

Lacerations Following Delivery Print​

Modified on: Fri, 20 Nov, 2020 at 3:53 PM
ANSWER:

The proper code to report will depend on the extent of the wound for a particular patient and the service performed and documented, to repair it. According to CPT, the repair of wounds may be classified as Simple, Intermediate, or Complex. For differentiation purposes:

Simple repair is used when the wound is superficial; e.g., involving primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures, and requires simple one-layer closure. This includes local anesthesia and chemical or electrocauterization of wounds not closed.

Intermediate repair includes the repair of wounds that, in addition to the above, require layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure. Single-layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter also constitutes intermediate repair.

Complex repair includes the repair of wounds requiring more than layered closure, viz., scar revision, debridement (e.g., traumatic lacerations or avulsions), extensive undermining, stents or retention sutures. Necessary preparation includes creation of a limited defect for repairs or the debridement of complicated lacerations or avulsions.

ACOG's position on reporting these repairs is as follows:

The repair of first and second degree lacerations are not to be reported separately. However, third and fourth degree lacerations extend beyond the perineum into areas such as the rectum and anus. Since these repairs require significant additional physician work, they are separately reportable.

ACOG’s Coding Committee recommends the following two options for reporting third and fourth degree lacerations repair:

Option 1

Append modifier 22 (Increased procedural services) to the appropriate delivery or global package code. Documentation describing the extent of the injury should be submitted with the claim.

Option 2

Depending on whether the repair is intermediate or complex, the physician can report a CPT-4 code from the Integumentary series, 12041—12047 (repair intermediate) or 13131—13133 (repair complex). The appropriate repair code would be reported in addition to the delivery or global package code.
 
Yes, you may charge for a third degree laceration repair. First & second degree are included in delivery. However, third & fourth degree repairs are appropriate to bill and should not be bundled with the delivery
 
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