I am new to OB coding.
Dr documented vaginal delivery with 2nd degree laceration but no episiotomy was done. My trainer coded it as 650 & V27.0 & I coded it as 664.11, V27.0
Code 664.1x says "following episiotomy"... so I was told to then code it as a 1st degree laceration since that code does not specify that it has to be following an episiotomy (even though op note says 2nd degree). So I asked... "then shouldn't we use the 1st degree 664.0x code instead of 650?" 650 says not to use with codes 630-676. Her thought was that a 1st degree laceration isn't really a complication to the delvery and therefore 650 would be correct.
1) Is it correct to 'downcode' to a 1st degree laceration?
2) How do I code for 2nd degree if no episiotomy was done?
3) If pt has a 1st degree laceration, do I code it or use 650?
Thank you!
Dr documented vaginal delivery with 2nd degree laceration but no episiotomy was done. My trainer coded it as 650 & V27.0 & I coded it as 664.11, V27.0
Code 664.1x says "following episiotomy"... so I was told to then code it as a 1st degree laceration since that code does not specify that it has to be following an episiotomy (even though op note says 2nd degree). So I asked... "then shouldn't we use the 1st degree 664.0x code instead of 650?" 650 says not to use with codes 630-676. Her thought was that a 1st degree laceration isn't really a complication to the delvery and therefore 650 would be correct.
1) Is it correct to 'downcode' to a 1st degree laceration?
2) How do I code for 2nd degree if no episiotomy was done?
3) If pt has a 1st degree laceration, do I code it or use 650?
Thank you!