EmailVaginal wall laceration with perineal laceration
Publication Date: June 2011
ICD 10 AM Edition: Seventh edition
Retired Date: 30/6/2017
Query Number: 2624
Does the excludes note at O71.4 Obstetric high vaginal laceration alone “Excludes: with perineal laceration (O70.-)“ mean that if a patient has a high vaginal laceration as well as a perineal laceration, that only the perineal tear can be coded, even if the vaginal wall tear is completely separate to the perineal tear?
The same question applies for the repair of the lacerations, i.e. if the two tears are repaired separately, are we only able to assign either 90481-00 [1344] or 16573-00 [1344] and not 90479-00 [1344] Suture of current obstetric laceration of vagina?
I have noted that under O70.0 that this code includes perineal graze, laceration, rupture or tear (involving): fourchette, labia, skin, slight, vagina and vulva. Under 90481-00 [1344] it includes repair of fourchette, labia, pelvic floor, skin, vaginal involvement NOS, and vulva.
However, in many cases a high vaginal wall tear is more significant than a perineal laceration and if we are only assigning a code for a perineal laceration, then it is not fully revealing the true extent and complexity of the patient’s laceration.
Is there a hierarchy of what code should be used? Should we assign O71.4 with 90479-00 [1344] over a code from O70.- and 90481-00 [1344] or 16573-00 [1344]?
The same question applies for the repair of the lacerations, i.e. if the two tears are repaired separately, are we only able to assign either 90481-00 [1344] or 16573-00 [1344] and not 90479-00 [1344] Suture of current obstetric laceration of vagina?
I have noted that under O70.0 that this code includes perineal graze, laceration, rupture or tear (involving): fourchette, labia, skin, slight, vagina and vulva. Under 90481-00 [1344] it includes repair of fourchette, labia, pelvic floor, skin, vaginal involvement NOS, and vulva.
However, in many cases a high vaginal wall tear is more significant than a perineal laceration and if we are only assigning a code for a perineal laceration, then it is not fully revealing the true extent and complexity of the patient’s laceration.
Is there a hierarchy of what code should be used? Should we assign O71.4 with 90479-00 [1344] over a code from O70.- and 90481-00 [1344] or 16573-00 [1344]?
Response
VICC confirms that the excludes note at O71.4 Obstetric high vaginal laceration alone 'Excludes: with perineal laceration (O70.-)' means that you only assign O70.x Perineal laceration during delivery for documentation of Vaginal wall laceration with perineal laceration.
VICC also confirms that if the two tears are repaired separately the appropriate codes to assign are 90481-00 [1344] Suture of first or second degree tear of perineum or 16573-00 [1344] Suture of third or fourth degree tear of perineum and not 90479-00 [1344] Suture of current obstetric laceration of vagina as per the excludes note at 90479-00 [1344].
There is no hierarchy as the excludes notes direct the coder to the appropriate codes from a classification point of view, however you may wish to consider submitting a public submission to the NCCC for review of the excludes notes.
VICC also confirms that if the two tears are repaired separately the appropriate codes to assign are 90481-00 [1344] Suture of first or second degree tear of perineum or 16573-00 [1344] Suture of third or fourth degree tear of perineum and not 90479-00 [1344] Suture of current obstetric laceration of vagina as per the excludes note at 90479-00 [1344].
There is no hierarchy as the excludes notes direct the coder to the appropriate codes from a classification point of view, however you may wish to consider submitting a public submission to the NCCC for review of the excludes notes.
