Wiki NVD with Second Degree Perineal tear

[Ravikirann]

Dear All,

One OB/GYN doubt as follows; Patient undergone NVD with episiotomy. The diagnosis is obviously NVD and in addition to this patient has second degree perineal tear. My doubt is if we code NVD we should not code any other complication since NVD (O80) is a stand alone code.Please advise how to code this scenario. This is an IP case the dx is both NVD and Second Degree tear.

Thanks In Advance
Ravi

 

[Amanda.Kane]

For this scenario you would not code the Normal Vaginal Delivery (O80) because the fact that there was a tear means the delivery is no longer considered normal. Your primary diagnosis would be the 2nd degree tear code, and then the outcome of delivery code. This can be found in your guidelines where it states "O80 is not to be used if any other code from Chapter 15 is needed to describe a current complication of the antenatal, delivery, or perinatal period.

Hope that helps!
Amanda Kane, CPC, COBGC