Q&A: ICD-10-PCS laceration repair guidance
Q: Our team had a recent case that involved a small midline episiotomy which extended to a second-degree laceration which was repaired with 3-0 vicryl rapide sutures. Would we code the episiotomy and repair or just the repair, and why? We are considering ICD-10-PCS code 0KQM0ZZ (Repair of the perineum muscle, open approach) and/or 0W8NXZZ (Division of the female perineum, external approach).
A: The two codes you identified are both viable options. This procedure can occur as either an episiotomy or a tear.
Although Coding Clinic has given advice for third- and fourth-degree laceration repair, there is no definitive guidance on this particular issue, therefore we can only provide an opinion.
If an episiotomy is considered to be to the depth of the perineal muscles then it would only be appropriate to report the second-degree laceration code. A second-degree laceration/tear involve injury to the vaginal wall and perineal muscle, but does not extend down into the anal sphincter muscle.
My advice would be to assign the ICD-10-PCS code 0KQM0ZZ.
Editor's note: Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS, answered this question. McCall is the director of HIM and coding for HCPro, an H3.Group division of Simplify Compliance LLC, in Middleton, Massachusetts, and oversees the Certified Coder Boot Camp programs. McCall works with hospitals, medical practices, and other healthcare providers on a wide range of coding-related custom education sessions.
This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate action.