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2025 ICD-10-CM code O71.82

Other specified trauma to the perineum and vulva during childbirth.

Follow the official ICD-10-CM coding guidelines for pregnancy, childbirth, and the puerperium.Ensure accurate documentation of the injury and its relationship to the delivery process.

Modifiers may be applicable depending on the circumstances of the delivery and any associated procedures performed.Consult the official modifier guidelines.

The medical necessity for coding O71.82 is established by the presence of a documented perineal or vulvar trauma directly related to the process of labor and delivery. The nature and extent of the injury warrant appropriate medical management.

Obstetrician/gynecologist or other qualified healthcare professional managing the childbirth.

IMPORTANT:May be used in conjunction with codes from category Z3A (Weeks of gestation) to specify the gestational age if known.Excludes obstetric periurethral trauma (O71.82).

In simple words: This code is used when a mother experiences an injury to the area between the vagina and anus (perineum) or the external female genitalia (vulva) during childbirth.This injury is not one of the specific types already listed in the medical codes.

This code classifies other specified trauma to the perineum and vulva that occurs during childbirth.It encompasses injuries not otherwise specified within the O71 category, such as specific lacerations or other forms of trauma to these areas, excluding obstetric periurethral trauma. The trauma must be directly related to the pregnancy, childbirth, or puerperium.

Example 1: A 32-year-old woman experiences a third-degree perineal laceration during vaginal delivery requiring surgical repair., A 28-year-old primiparous woman sustains a vulvar hematoma during a forceps-assisted delivery., A 40-year-old multiparous patient undergoes an episiotomy, and during the procedure a small, unexpected laceration occurs to the posterior fourchette.

Complete obstetric history, documentation of the delivery method, detailed description of the injury (location, size, depth, etc.), type of repair performed (if any), and any complications.

** This code should only be used for maternal records and not for newborn records.The injury must be directly caused by or aggravated by the pregnancy, childbirth, or the puerperium.

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