AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2014 Issue 4; Ask the Editor

Second Degree Obstetric Perineal Laceration

By definition, a second degree perineal laceration involves rupture or tearing of the perineal muscle(s). Would physician documentation stating, “Second degree perineal laceration repair” be sufficient to justify assigning an ICD-10-PCS repair code (0KQM0ZZ)? Or, is it required that the documentation specify “perineal muscle”? ...

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