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An episiotomy or vaginal repair is a surgical procedure performed to address lacerations that occur during vaginal delivery. This procedure is specifically conducted by a physician or a qualified healthcare professional who is not the attending physician responsible for the delivery. During childbirth, perineal lacerations can occur, which are classified into four degrees based on their depth. The depth of the laceration determines the complexity of the repair required. For instance, a fourth-degree laceration, which is the most severe, necessitates a meticulous repair that includes the rectal mucosa and both the internal and external anal sphincters. The repair process involves exposing these structures by retracting the vaginal sidewalls, identifying the apex of the rectal mucosal injury, and suturing it to restore integrity. The internal anal sphincter is also repaired, followed by the external anal sphincter using an end-to-end technique. In cases of second-degree lacerations, the repair begins with identifying the apex of the vaginal laceration and placing an anchoring suture. The procedure continues with suturing the vaginal mucosa and rectovaginal fascia, ensuring proper anatomical alignment of the perineal muscles. This careful approach aims to achieve optimal healing and restore function, often without the need for skin sutures, although running subcuticular sutures may be employed if necessary.
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The procedure of episiotomy or vaginal repair is indicated for the following conditions:
The procedure for episiotomy or vaginal repair involves several critical steps to ensure proper healing and restoration of anatomical integrity:
Post-procedure care involves monitoring the repair site for any signs of infection or complications. Patients are typically advised on proper hygiene practices to promote healing and may receive instructions on pain management. Follow-up appointments are essential to assess the healing process and address any concerns that may arise during recovery. The expected recovery time can vary based on the severity of the laceration and the repair performed, but patients are generally encouraged to gradually resume normal activities as tolerated.
| Short Descr | EPISIOTOMY OR VAGINAL REPAIR | Medium Descr | EPISIOTOMY/VAG RPR OTH/THN ATTENDING | Long Descr | Episiotomy or vaginal repair, by other than attending | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 1 | CCS Clinical Classification | 140 - Repair of current obstetric laceration |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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| 2013-01-01 | Changed | Description Changed |
| Pre-1990 | Added | Code added. |
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