Chapter 15 Part 6 lacerations

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 Scenarios for Obstetric Lacerations and Hematoma:


First-degree tear:


Definition: Damage to the fourchette and vaginal mucosa, with exposed underlying muscles that are not torn.

ICD-10-CM Code: O70.0 (First-degree perineal laceration)

ICD-10-PCS Code for Repair: 0W8G0ZZ (Repair of vaginal mucosa and underlying muscles, open approach)

Second-degree tear:


Definition: Involves the posterior vaginal walls and perineal muscles, but the anal sphincter remains intact.

ICD-10-CM Code: O70.1 (Second-degree perineal laceration)

ICD-10-PCS Code for Repair: 0W8H0ZZ (Repair of posterior vaginal walls and perineal muscles, open approach)

Third-degree tear:


Definition: Extends to the anal sphincter, but the rectal mucosa remains intact.

ICD-10-CM Code: O70.2- (Third-degree perineal laceration, additional fifth digits required)

ICD-10-PCS Code for Repair: 0W8J0ZZ (Repair of anal sphincter, open approach)

Fourth-degree tear:


Definition: Involves the rectal and anal mucosa.

ICD-10-CM Code: O70.3 (Fourth-degree perineal laceration)

ICD-10-PCS Code for Repair: 0W8K0ZZ (Repair of rectal and anal mucosa, open approach)

Obstetric hematoma of the pelvis:


Definition: Hematoma occurring as a result of obstetric trauma.

ICD-10-CM Code: O71.7 (Obstetric hematoma of pelvis)

ICD-10-PCS Code for Treatment: 0XHU0Z2 (Drainage of pelvic hematoma, percutaneous approach)

Note: The ICD-10-PCS codes provided for repair and treatment are fictional examples and should not be used for actual coding. The specific approach and technique for repair or treatment may vary based on the clinical scenario and documentation.


It is essential to consult the complete ICD-10-CM and ICD-10-PCS code sets, as well as the official coding guidelines, for accurate code assignment based on the specific documentation provided for each scenario.





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