Wiki Help with ICD code for laceration for both labial and vaginal during delviery

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tblmt1966

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The provider documented the following regarding the laceration during delivery. Would I be correct in only coding the O71.4?

Bleeding was minimal. Perineum, vagina, cervix were inspected, and right labial and left vaginal lacerations were identified. Laceration was repaired with 3-0 Vicryl on CT, Hemostasis and skin approximation achieved and maintained with repair. All sponge/lap/instruments were counted, and counts were verified.
Lacerations
Episiotomy: None
Perineal laceration: None
Labial laceration? Yes
Labial laceration location: right
Labial laceration repaired: Yes
Vaginal laceration? Yes
Vaginal laceration location left
Vaginal laceration repaired? Yes
Repair suture: 3-0 Vicry
 
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tblmt1966 said:
The provider documented the following regarding the laceration during delivery. Would I be correct in only coding the O71.4?

Bleeding was minimal. Perineum, vagina, cervix were inspected, and right labial and left vaginal lacerations were identified. Laceration was repaired with 3-0 Vicryl on CT, Hemostasis and skin approximation achieved and maintained with repair. All sponge/lap/instruments were counted, and counts were verified.
Lacerations
Episiotomy: None
Perineal laceration: None
Labial laceration? Yes
Labial laceration location: right
Labial laceration repaired: Yes
Vaginal laceration? Yes
Vaginal laceration location left
Vaginal laceration repaired? Yes
Repair suture: 3-0 Vicry
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As the patient had both a perineal and vaginal laceration, ICD10 instructs you to use O70.0 instead (see included terms under code O70.0).
 
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Yes, there is specifically an excludes1 note on O71.4
O71.4 Obstetric high vaginal laceration alone
Laceration of vaginal wall without perineal laceration
Excludes1: obstetric high vaginal laceration with perineal laceration (O70.-)
 
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