The patient presented at 39-weeks gestation for delivery. Due to maternal exhaustion, the decision was made to proceed with assisted vaginal delivery. First a vacuum was placed and assistance was given over the course of four contractions with downward progress of the head. Low forceps were then applied to deliver the infant. In ICD-10-PCS, when vaginal delivery is assisted using a vacuum to bring the baby to a lower station, along with the application of forceps, should both methods of assisted delivery be coded? Or is only the low forceps extraction coded?
The vacuum was used to assist in the labor to bring the baby down to a lower station. In terms of the delivery, only forceps were used in the actual extraction procedure to deliver the baby. Since the same root operation was performed on the same body part, it does not meet the definition of multiple procedures. Assign only the ICD-10-PCS code for the low forceps extraction as follows:
10D07Z3 Extraction of products of conception, low forceps, via natural or artificial opening