This is a 30-year-old patient who had a previous cesarean section for delivery due to fetal distress. During this pregnancy, she has had routine antepartum care with no complications. We are going to attempt a vaginal birth after cesarean (VBAC) for this delivery.

She is admitted at 39 completed weeks, in labor. The fetus is in cephalic position and no rotation is necessary.

The labor continues to progress and five hours later she is taken to delivery. During the delivery she is fatigued, so mid forceps are required over a midline episiotomy that was subsequently repaired by an episiorrhaphy.

A single liveborn infant is delivered.

Case Study 10

ICD-10-PCS Coding Guideline C.1 states that the Obstetrics section includes only the procedures performed on the products of conception.

Procedures performed on the pregnant female other than the products of conception are coded to a root operation in the Medical and Surgical section.

Products of conception refer to all components of pregnancy, including fetus, embryo, amnion, umbilical cord, and placenta. There is no differentiation of the products of conception based on gestational age. Therefore, since the mid forceps delivery is performed on the fetus, it is coded to the Obstetrics section of ICD-10-PCS.

The use of the mid forceps to deliver the fetus is coded to the root operation Extraction. Extraction is defined as the pulling or stripping out of all or a portion of a body part. In this case, the mid forceps are used to pull out the body part (products of conception).

The episiotomy is coded to the Medical and Surgical section because it is performed on the pregnant female. The code for episiotomy is 0W8NXZZ.

The main term Episiotomy in the Alphabetic Index refers the coding professional to “see Division, Perineum, Female (0W8N).”

The root operation Division is coded when the objective of the procedure is to cut into, transect, or otherwise separate all or a portion of a body part.

The episiorrhaphy is not coded separately, per ICD-10-PCS Guideline B3.1b which states that procedural steps necessary to reach the operative site and close the operative site are not coded separately.