postpartum check of vaginal repair

tag60

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Please help me with a diagnosis code for this patient who is 9 days status post vaginal delivery.

Per note: No episiotomy was done, but required repair. Exam of external vaginal: 2 stitches each labia and 4 stitches sulcus.

A/P: Tear of vaginal wall. Recommend hot sitz baths twice daily and return in 1-2 weeks for recheck.

Would this be O70.0, first-degree perineal laceration during delivery -- or is this no longer the current condition (since it was repaired)?
Or would I use an aftercare code, perhaps Z48.817, Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue...??

Thanks in advance!
 

Bernadette10

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Followup visit after perineal laceration repair after delivery

Please help me with a diagnosis code for this patient who is 9 days status post vaginal delivery.

Per note: No episiotomy was done, but required repair. Exam of external vaginal: 2 stitches each labia and 4 stitches sulcus.

A/P: Tear of vaginal wall. Recommend hot sitz baths twice daily and return in 1-2 weeks for recheck.

Would this be O70.0, first-degree perineal laceration during delivery -- or is this no longer the current condition (since it was repaired)?
Or would I use an aftercare code, perhaps Z48.817, Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue...??

Thanks in advance!
I have this same question. I think I would go with Z48.89 other specified aftercare since the laceration repair was included in the delivery and not coded separately. I wouldn't use the pregnancy code since the patient is no longer pregnant, and this visit isn't part of the hospital admission. If the laceration was completely healed I would use Z09.
 

KellyLR

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Hi,

If this was follow-up care, wouldn't this be part of the global package 59410? If the purpose of the visit was to only check the laceration healing, then I wouldn't think it would get coded separately. ACOG website has lots of information as go-by. Now if the laceration was more complex than second degree then ACOG would have specifics on how this would be reported if it is reported since this is a check with no active care involved during the followup. You could also use Modifier 22 to the delivery package code and try that.
 
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