Ob-Gyn Coding Alert

Question: Patient has a normal spontaneous vaginal delivery (NSVD) with bilateral sulcus tear. My ob-gyn’s documentation says it took about an hour to complete the repair, but I can’t say that it was a third degree. Is there a code for a long repair? Or is that bundled into the global fee?

New York Subscriber

Answer: The diagnosis code for this would be 665.41 (High vaginal laceration with delivery). In ICD-10, this code will become O71.4 (Obstetric high vaginal laceration alone).

You won’t find any appropriate CPT® code for repair of a vaginal laceration (as opposed to a perineal laceration) since the vaginal canal is not "external genitalia" as referred to in the integumentary repair codes. Your option here is to add a modifier 22 (Increased procedural service) to the delivery code or report the repair as a multiple procedure using the unlisted code 59899 (Unlisted procedure, maternity care and delivery) and comparing the work to 57200 (Colporrhaphy, suture of injury of vagina [nonobstetrical]) (which you can’t report since this is a non-ob code).