AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2013 Issue 4; Ask the Editor

Excision of Inclusion Cyst of Perineum

A 34-year-old patient presented for delivery. The patient had a normal vaginal delivery and the placenta was delivered spontaneously. The patient had second degree perineal lacerations which were repaired in layers. It was noted during the repair that the patient had an inclusion cyst of the perineum that was excised. We are not sure about the correct body system to use for this procedure. Would the cyst of the perineum be considered a “general anatomical region” or “subcutaneous tissue and fascia”? The body part value for perineum exists under both options but we are unsure about the appropriate body system. Additionally, guideline B2.1a in the Official Coding Guidelines for ICD-10-PCS states that procedure codes in the general anatomical regions body system should only be used when the procedure is performed on an anatomical region rather than a specific body part. What is the appropriate ICD-10-PCS code assignment for excision of inclusion cyst of perineum?     ...

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