Clinical Context
A 28-year-old female presents to the labor and delivery unit after a spontaneous vaginal delivery with a second-degree perineal laceration involving the vaginal mucosa and underlying perineal muscle. The obstetrician evaluates the wound immediately postpartum, administers local anesthesia, irrigates and debrides devitalized tissue as needed, and performs layered closure of the vaginal mucosa and perineal muscles with absorbable sutures to restore anatomy and hemostasis. Typical workflow includes pre-procedure consent and verification, analgesia (local or regional already in place), procedural time-out, layered repair in the delivery room or procedure suite, documentation of laceration degree and repair technique, post-procedure wound care instructions, and follow-up in the postpartum clinic.
Coding Specifications
| Modifier | Description | When to Use |
|---|
22 | Increased procedural services | Use when work, time, or complexity substantially exceeds usual for a standard perineal repair. |
23 | Unusual anesthesia service | Use when general anesthesia is medically necessary for the repair.
26 | Professional component | Use when billing only the physician component of a split-bill service (rare for this procedure).
50 | Bilateral procedure | Use if bilateral procedures are reported (typically not applicable to midline perineal repair).
51 | Multiple procedures | Use when other distinct procedures are performed the same day and multiple-procedure rules apply.
52 | Reduced services | Use when the repair is partially reduced or not completed as originally planned.
53 | Discontinued procedure | Use when the procedure is terminated due to extenuating circumstances.
58 | Staged or related procedure by same physician | Use if a planned second-stage repair is performed later.
59 | Distinct procedural service | Use to indicate a separate, distinct repair or other procedure performed on the same day.
62 | Two surgeons | Use when two surgeons work together as primary surgeons during a complex repair.
66 | Surgical team | Use when a surgical team approach is required for complex reconstruction.
76 | Repeat procedure by same physician (note: not in provided list) | Data not available in the input.
78 | Unplanned return to the operating/procedure room | Use if the patient returns for revision or bleeding control related to the repair.
80 | Assistant surgeon | Use when an assistant surgeon is present and reimbursement rules require the modifier.
| Taxonomy Code | Specialty | Notes |
|---|
207P00000X | Obstetrics & Gynecology | Obstetricians commonly perform postpartum perineal laceration repairs. |
208800000X | Family Medicine | Family physicians with obstetric privileges may perform repairs in some settings.
207QA0000X | Certified Nurse Midwife | Midwives frequently perform primary perineal repairs in labor and delivery.
208VP0003X | General Practice | General practitioners in rural settings may perform repairs.
363L00000X | Plastic Surgery | Plastic surgeons may be involved for complex perineal reconstruction or revision.
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|
O70.1 | Second degree perineal laceration during delivery | Direct indication for repair of perineal muscle and vaginal mucosa. |
O70.0 | First degree perineal laceration during delivery | Minor mucosal/skin repair; may not require layered muscle repair but related.
O70.2 | Third degree perineal laceration during delivery | Involves anal sphincter; may require more extensive repair and specialist involvement.
O70.3 | Fourth degree perineal laceration during delivery | Extends to rectal mucosa; requires complex repair and possible colorectal consultation.
O70.8 | Other specified perineal lacerations during delivery | Captures atypical lacerations requiring individualized repair.
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|
12032 | Repair, intermediate, wounds of scalp, arms, and/or legs; 2.6 cm to 7.5 cm | Sometimes used for intermediate layered soft tissue repairs when similar technique coding is needed for non-obstetric perineal soft tissue repair scenarios. |
57240 | Repair of rectocele, with or without repair of enterocele; via vaginal approach | Performed when posterior compartment defects or rectocele are identified and require concurrent repair.
57454 | Colposcopy including upper/adjacent vaginal assessment with biopsy (separate procedure) | May be performed if there is concern for mucosal injury requiring biopsy during evaluation.
58140 | Vaginal repair, postpartum, including repair of laceration or episiotomy | Often reported for more extensive postpartum vaginal repairs when coding differs by payer/local guidance.
99100 | Anesthesia for procedures on lower abdomen, perineum and pelvis when concurrent with other procedures (add-on) | Used to report additional anesthesia complexity when required for perineal repair.