ICD-10 Coding for Repair of Vaginal Laceration(0KQM0ZZ, 0DQP0ZZ)
Complete ICD-10-CM coding and documentation guide for Repair of Vaginal Laceration. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Repair of Vaginal Laceration
0KQM0ZZ-0DQP0ZZPrimary Range
ICD-10-PCS codes for repair of perineal and rectal structures
These codes cover the surgical repair of vaginal and perineal lacerations, including muscle and sphincter involvement.
ICD-10-CM code for open wound of vagina
This code is used for non-obstetric vaginal lacerations.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| 0KQM0ZZ | Repair perineum muscle, open approach | Use for second-degree perineal lacerations involving muscle. |
|
| 0DQP0ZZ | Repair rectum, open approach | Use for fourth-degree lacerations involving rectal mucosa. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for repair of vaginal laceration
Essential facts and insights about Repair of Vaginal Laceration
Primary ICD-10-CM Codes for procedure repair vaginal laceration
Decision Criteria
clinical Criteria
- Presence of muscle involvement in laceration
documentation Criteria
- Open approach documented
Applicable To
- Second-degree perineal laceration repair
Excludes
- First-degree lacerations
Clinical Validation Requirements
- Documentation of muscle involvement
- Open surgical approach
Code-Specific Risks
- Undercoding if muscle involvement is not documented
Coding Notes
- Ensure documentation specifies muscle involvement and open approach.
0DQP0ZZ - Repair rectum, open approach
Use for fourth-degree lacerations involving rectal mucosa.
Applicable To
- Fourth-degree laceration repair
Clinical Validation Requirements
- Documentation of rectal mucosa involvement
- Open surgical approach
Coding Notes
Ensure documentation specifies rectal involvement and open approach.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Repair anal sphincter, open approach
0DQR0ZZDifferential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Repair skin, external approach
0HQEXZZDocumentation & Coding Risks
Avoid these common documentation and coding issues when documenting Repair of Vaginal Laceration to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code 0KQM0ZZ.
Impact
Clinical: May lead to inappropriate follow-up care., Regulatory: Non-compliance with coding standards., Financial: Potential for denied claims.
Mitigation Strategy
Use templates that prompt for approach documentation., Educate staff on documentation standards.
Impact
Reimbursement: Incorrect coding may lead to lower reimbursement., Compliance: May trigger audits due to incorrect code usage., Data Quality: Affects accuracy of clinical data.
Mitigation Strategy
Use specific codes like 59300 for obstetric repairs during delivery.
Impact
Inadequate documentation of the depth can lead to incorrect coding.
Mitigation Strategy
Ensure detailed documentation of all layers involved in the laceration.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Repair of Vaginal Laceration, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Repair of Vaginal Laceration
Use these documentation templates to ensure complete and accurate documentation for Repair of Vaginal Laceration. These templates include all required elements for proper coding and billing.
Obstetric 3rd-Degree Tear
Specialty: ObstetricsRequired Elements
- Laceration degree
- Layers involved
- Approach
- Suture material
- Rectal exam findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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