AHA Coding Clinic® for HCPCS - 2023 Issue 2; Ask the Editor

Second-degree postpartum laceration repair by other physician

A patient who delivered several days prior, presented for treatment of delayed postpartum hemorrhage. Examination revealed an extensive 1.5 cm perineal/vaginal laceration with evidence of prior repair. All visible sutures were removed. A pumping artery was noted on the patients’ right side, just inside the vaginal vault. The laceration appeared to be a deep second-degree with perineal tear and extension to the left inner labia. Attention was then turned to repairing the vaginal and perineal laceration. A 2-0 vicryl was used starting at the left apex and working towards the vaginal opening. The suturing was continued up the left inner labial laceration for re-approximation. A second 2-0 vicryl stitch was placed in the area of active bleeding on the right vaginal wall. A 2-0 vicryl stitch was placed above the apex on the right side and continued down in standard OB fashion. Tissues reapproximated and bleeding was minimal. The area was again inspected, and hemostatic appearing. In this case, the physician performing the repair did not perform the delivery. How is the second-degree perineal repair reported? ...

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