AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2018 Issue 2; Clarifications

Repair of Third and Fourth Degree Obstetric Laceration

According to Coding Clinic First Quarter 2016, pages 6-8, multiple codes are not assigned for repair of a third or fourth degree obstetric perineal tear, because it is coded to the “deepest layer.” The article states, “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.” The term “beneath” has been a source of confusion to coding professionals, since it is not a medical term. A third degree perineal tear involves the perineum, which is the area between the anus and the posterior part of the external genitalia and the anal sphincter. A fourth degree tear involves the perineum, anal sphincter, and rectum. These structures can be considered adjacent, but not overlapping. Therefore, unique codes should be assigned for repair of third and fourth degree perineal tears that describe each body part (i.e., anal sphincter and rectum) depending on the degree and body part involved. Please reconsider the previously published coding advice for these types of repairs. ...

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