Elective caesarean section with scar excision

Created Apr 2016
Reviewed Dec 2019

Query

Obstetric patient was admitted for an elective caesarean section.  Indication was previous C-section delivery. 
At the operation it was planned to excise a keloid scar that formed at the incision site first and then perform the C-section.

Are additional diagnosis and procedure codes required in addition to the instructions of ACS 1506 Fetal presentation, disproportion and abnormality of maternal pelvic organs?

If additional diagnosis and procedure codes are to be used, what should they be?

Our suggestion after reviewing the documentation and seeking clinical clarification is to assign the additional codes:
O99.7   Diseases of the skin and subcutaneous tissue in pregnancy, childbirth and the puerperium
L91.09  Hypertrophic scar due to other specified cause
45518-00 [1657] Revision of scar of other site

Does NZCA agree with the additional codes?

Response

Where there is clinical documentation specifying a problem with the previous caesarean scar (e.g. keloid scar, painful scar) and it meets ACS 0002 Additional diagnoses (e.g. scar excision prior to caesarean) then the appropriate codes to assign in addition to other obstetric conditions (e.g. O34.2 Maternal care due to uterine scar from previous surgery) are:

O99.7   Diseases of the skin and subcutaneous tissue in pregnancy, childbirth and the puerperium
L91.09  Hypertrophic scar due to other specified cause

Excision of scar procedure.  Where there is no documentation of the scar length 45515-00 [1657] Revision of scar of other site <= 7 cm in length should be assigned as per the ACHI index.

 

Back to top