Wiki ICD-10CM for Vaginal laceration during Delivery.

[natashalage]

Hello Coding community,
I need your help, please. During a delivery "Perineum was inspected and found to have a bilateral vaginal degree laceration, repaired with a 3-0 Vicryl Rapide in the standard fashion"
I am not sure what dx code I should use: was it with 'perineal laceration'? or 'high vaginal"?

Should I code it as O70.0-First degree perineal laceration during delivery or O71.4- Obstetric high vaginal laceration alone?

I think it’s O71.4 because MD mentioned "Perineum” and it’s seems like a simple repair (not like we would see for High Vaginal O70.0 I think). O70.0 is lesser by severity than O71.4 a High vaginal.

I found the following types of vaginal lacerations in ICD-10CM:

O70.0- 1st degree perineal laceration with: labia, vulva. O70.1- 2nd degree with vaginal muscles

O71.4- Obstetric High vaginal alone ( without perineal laceration)
Which icd-10 code would be correct to assign?
Thank you very much for your help in advance.

 

[nielynco]

Hello Coding community,
I need your help, please. During a delivery "Perineum was inspected and found to have a bilateral vaginal degree laceration, repaired with a 3-0 Vicryl Rapide in the standard fashion"
I am not sure what dx code I should use: was it with 'perineal laceration'? or 'high vaginal"?

Should I code it as O70.0-First degree perineal laceration during delivery or O71.4- Obstetric high vaginal laceration alone?

I think it’s O71.4 because MD mentioned "Perineum” and it’s seems like a simple repair (not like we would see for High Vaginal O70.0 I think). O70.0 is lesser by severity than O71.4 a High vaginal.

I found the following types of vaginal lacerations in ICD-10CM:

O70.0- 1st degree perineal laceration with: labia, vulva. O70.1- 2nd degree with vaginal muscles

O71.4- Obstetric High vaginal alone ( without perineal laceration)
Which icd-10 code would be correct to assign?
Thank you very much for your help in advance.

I would as your provider as bilateral vaginal degree laceration does not give you the degree of laceration so you can figure this out and he says he inspected the perineum, not the vaginal canal. If it was a simple repair, then probably only a first or second degree repair and not a vaginal laceration.

 

[natashalage]

Dear Nielynco, Thank you very much for your response! Thank for answering our questions in this forum and sharing your knowledge along with other experts like Csperoni and Cmama! Yes, we are learning and way to go but it's FUN.