2025 ICD-10-CM code O71
Other obstetric trauma. This includes any obstetric damage resulting from the use of instruments.
Medical necessity for interventions related to the trauma should be documented.
The physician attending the delivery is responsible for documenting and coding any obstetric trauma.
In simple words: This code represents injuries during childbirth not otherwise specified, including those caused by instruments.
This code encompasses other forms of obstetric trauma not classified elsewhere, including damage from instruments used during delivery.
Example 1: A patient experiences a perineal laceration during a forceps delivery that doesn't fit into other O71 subcategories. Code O71 is used., A patient sustains a cervical laceration during a vacuum-assisted delivery not categorized under other subcategories of O71. O71 is applied., During a complicated delivery, the patient's bladder is inadvertently injured by instruments. This would be coded as O71.5.
Thorough documentation of the trauma, including the cause, location, and severity of the injury, is essential for proper coding.
** This code is used only on the maternal record, never on the newborn record.
- Specialties:Obstetrics and Gynecology
- Place of Service:Inpatient Hospital, Birthing Center