Coding haemorrhage secondary to perineal tear repair
Created Jun 2016
Reviewed Dec 2019
Patient had a 2.8 litre postpartum haemorrhage (PPH) from an “uncontrolled perineal laceration” that had been sutured at the time of delivery. There is no index entry for PPH secondary to laceration. The default code for PPH is O72.1 Other immediate postpartum haemorrhage. There is an index entry, Complications/perineal wound, obstetric (puerperal) NEC O90.8 Other complications of the puerperium, NEC.
Which is the best diagnosis code to assign?
As the haemorrhage (bleeding) was a complication of a repaired perineal laceration following delivery, which required a secondary perineal repair to control the bleeding assign O90.8 Other complications of the puerperium following the ICD-10-AM Alphabetic Index: Complications/perineal wound, obstetric (puerperal) NEC. Free text should be used to add specificity.
PPH was documented in the clinical record however the haemorrhage (bleeding) was from the uncontrolled perineal laceration and not from a uterine/placental problem e.g. retained placenta. Also the treatment provided to control the haemorrhage did not involve the standard treatment for a PPH e.g. administration of oxytocin. Therefore, to accurately classify ‘haemorrhage from uncontrolled perineal laceration following repair’, O90.8 Other complications of the puerperium, NEC is the most appropriate code to assign in this case.