Wiki Vaginal laceration, OB

[desireewhite185@yahoo.com]

Hello,
Looking for advice on a delivery, patient had to be brought to the Operating room after delivery for repair of complex vaginal laceration.


I am not sure about the CPT or the diagnosis really. Diagnosis I was thinking O71.4, but there is also perineal laceration. And rectum exposed. The CPT I was looking at 12041 or 13131, but there is no measurements and it's not exactly those. Any help appreciated. Thanks, Des

 

[nielynco]

Hello,
Looking for advice on a delivery, patient had to be brought to the Operating room after delivery for repair of complex vaginal laceration.

View attachment 6693
I am not sure about the CPT or the diagnosis really. Diagnosis I was thinking O71.4, but there is also perineal laceration. And rectum exposed. The CPT I was looking at 12041 or 13131, but there is no measurements and it's not exactly those. Any help appreciated. Thanks, Des

Your diagnosis code will be O70.3 (Fourth degree perineal laceration during delivery) as this code includes a tear up into the vaginal muscle and the rectum. As to the code, he is not describing a complex repair as the requirements for that code (13131 for instance) are not documented. Below is the requirement by CPT. I would normally bill this as an intermediate repair given the verbiage, but since he does not indicate the size of the wound you will have to settle for 12041 or go back to the provider and ask for more information.

CPT states the following:
Intermediate repair (such as 12041) includes the repair of wounds that requires layered closure of one or more of the deeper layers of subcutaneous tissue and in which superficial (non-muscle) fascia is required in addition to the skin (epidural and dermal) closure. Intermediate repair includes limited undermining, which is defined as a distance less than the maximum width of the defect, measured perpendicular to the closure line, along at least one entire edge of the defect. Intermediate repair may also be reported for single-layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter.

For a complex repair code to be reported (such as 13131), the CPT guidelines clarify that the repair must include all the requirements listed for intermediate repair plus at least one of the following:
• repair of exposed bone, cartilage, tendon, or a named neurovascular structure;
• debridement of wound edges;
• extensive undermining (see Figure l);
• involvement of free margins of the helical rim, vermillion border, or nostril rim; or
• placement of retention sutures.

 

[desireewhite185@yahoo.com]

Your diagnosis code will be O70.3 (Fourth degree perineal laceration during delivery) as this code includes a tear up into the vaginal muscle and the rectum. As to the code, he is not describing a complex repair as the requirements for that code (13131 for instance) are not documented. Below is the requirement by CPT. I would normally bill this as an intermediate repair given the verbiage, but since he does not indicate the size of the wound you will have to settle for 12041 or go back to the provider and ask for more information.

CPT states the following:
Intermediate repair (such as 12041) includes the repair of wounds that requires layered closure of one or more of the deeper layers of subcutaneous tissue and in which superficial (non-muscle) fascia is required in addition to the skin (epidural and dermal) closure. Intermediate repair includes limited undermining, which is defined as a distance less than the maximum width of the defect, measured perpendicular to the closure line, along at least one entire edge of the defect. Intermediate repair may also be reported for single-layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter.

For a complex repair code to be reported (such as 13131), the CPT guidelines clarify that the repair must include all the requirements listed for intermediate repair plus at least one of the following:
• repair of exposed bone, cartilage, tendon, or a named neurovascular structure;
• debridement of wound edges;
• extensive undermining (see Figure l);
• involvement of free margins of the helical rim, vermillion border, or nostril rim; or
• placement of retention sutures.

Thank you very much for your time and knowledge. Desiree