Questioning the recent Coding Clinic perineal laceration repair guidance

by Erica E. Remer, MD, FACEP, CCDS

A recent Coding Clinic has garnered a lot of questions on inpatient obstetrics coding.

While coders were originally taught to use multiple codes for the repair of a third- or fourth-degree perineal laceration, Coding Clinic, First Quarter 2016, states that you don’t use multiple codes for third- and fourth-degree tears, because you need to code to the “deepest layer.” 

According to this Coding Clinic (emphasis added):

Assign code 0DQR0ZZ, Repair anal sphincter, open approach, for the repair of a third-degree obstetric perineal laceration. ICD-10-PCS Guideline B3.5 states: "If the root operation Excision, Repair or Inspection is performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is coded." In the context of a third-degree obstetric laceration, the anal sphincter muscle is beneath the perineal muscle and is therefore the deepest layer in this scenario.

They included a question about a patient who had a spontaneous vaginal delivery and experienced an obstetric fourth-degree perineal laceration, and wondered if a code should be assigned separately for each body part (such as the perineum and anal sphincter) or if the repair should only be coded to the deepest layer when multiple layers are involved (such as skin, subcutaneous, muscle, etc.). Coding Clinic said to assign 0DQP0ZZ, Repair rectum, open approach, for the repair of the fourth-degree tear since, as stated above, you should code the deepest layer involved in the tear.

Speaking as a clinician, this is flawed advice. “Beneath” is not medical terminology, and it is probably the source of the confusion. When talking about depth of a layer, in medical lexicon, you are usually going from the external toward the center of the body, not superior to inferior.

Editor’s Note: The above is an excerpt from JustCoding’s Briefings on Coding Compliance Strategies. Read more on this topic here. Dr. Remer is founder and president of Erica Remer, MD, Inc., Consulting Services. Contact her at icd10md@outlook.com. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.