Health Information Management

Coding Q&A

HIM-HIPAA Insider, September 10, 2012

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Q. How do a cervical/vaginal laceration complication/repair and a routine episiotomy performed for ease during delivery differ?

A. A routine episiotomy is a procedure during which a surgeon performs a surgically planned, less-than-second-degree incision on the vulva/vagina area or region to prevent a more serious laceration or tear at the time of vaginal delivery. The incision is usually only 1–2 centimeters
in length. A cervical/vaginal complication occurs when there is a laceration of the cervix or the high vaginal area that occurs naturally at the time of delivery.
Coders must review documentation to ascertain whether the patient had a routine episiotomy or whether a cervical or high-vaginal tear/laceration occurred at the time of delivery. Sometimes the high-vaginal tear/laceration occurs in addition to an episiotomy. Many coders forget to code the complication.
Editor’s note: Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBG, a coder at St. Alphonsus Regional Medical Center in Boise, Idaho, and an AHIMA-certified ICD-10-CM/PCS trainer, answered this question in the September edition of Briefings on Coding Compliance Strategies.

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