Health Information Management

Q&A: PCS coding for perineal laceration

CDI Strategies, October 1, 2015

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Q: I am having trouble with the procedure (PCS) coding for a perineal laceration repair. Some sources state that the correct code uses the perineal anatomic region, not muscle repair. Would you please clarify the correct ICD-10-PCS code for a second degree obstetrical (perineum) laceration that includes muscle?

A: This is a challenging area of ICD-10-PCS coding. Repair of obstetric lacerations documentation can often lead to miscoding, so we need to clearly document perineal lacerations and related treatments.

There is conflicting guidance online regarding this procedure, but the Coding Clinic, Fourth Quarter 2013, p. 120 does provide a definitive example to clarify appropriate code assignment. It discusses the case of a 25-year-old patient who had a normal spontaneous vaginal delivery at 39 weeks gestation and suffered a second degree perineum laceration. The repair involved suturing of the muscle.

In this instance, Coding Clinic says to assign code 0KQM0ZZ, repair perineum muscle, open approach. In ICD-10-PCS, an “open” approach is defined as cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure. In this case, “open approach” is assigned because the laceration has cut through the external body layers, exposing the muscle (i.e. site of the procedure).

Although the laceration occurred spontaneously, it is nevertheless the means by which the procedure site is exposed. The same principle would apply for a laceration repair caused by other means, such as a knife wound that lacerates the liver.

Editor’s Note: Mark Morsch, MS, AHIMA-Approved ICD-10-CM/PCS Trainer, vice president of technology for Optum360, and Tom Darr, MD, chief medical officer for Optum360, answered this question. To access their free webcast, “Beyond the Planning: Post-Implementation Strategies for CDI and ICD-10,” presented by Optum360 and hosted by ACDIS, click here.


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