2025 ICD-10-CM code O71.4
(Active) Effective Date: N/A Pregnancy, childbirth and the puerperium - Complications of labor and delivery 15 Feed
Obstetric high vaginal laceration alone. Laceration of vaginal wall without perineal laceration.
Repair of an obstetric high vaginal laceration is medically necessary to control bleeding and prevent complications such as infection and long-term vaginal or pelvic floor dysfunction.
The physician attending the delivery is responsible for diagnosing and managing obstetric high vaginal lacerations. This includes assessing the extent of the tear, controlling bleeding, and performing the repair.Proper documentation of the location and depth of the laceration is essential.
In simple words: This code indicates a tear in the upper part of the vagina during childbirth, not involving the area around the vaginal opening.
Obstetric high vaginal laceration alone.This code describes a laceration of the middle or upper third of the vaginal wall, or the vaginal sulcus, occurring during delivery. It excludes lacerations of the lower vagina and perineal lacerations.
Example 1: A patient experiences a spontaneous vaginal delivery and the physician notes a tear in the upper vaginal wall, but no perineal involvement.Code O71.4 is assigned., During a forceps-assisted delivery, the physician documents a laceration to the vaginal sulcus, with no other trauma noted. Code O71.4 is applicable., Following a vaginal delivery, a patient is found to have a deep tear in the upper vagina, requiring extensive repair. Code O71.4 is used.
Documentation should clearly specify the location (upper/middle third of vagina, vaginal sulcus) and depth of the laceration.The method of delivery (spontaneous, assisted) should also be documented. If other perineal or cervical lacerations are present, they should be coded separately.
- Specialties:Obstetrics and Gynecology
- Place of Service:Inpatient Hospital, Birthing Center