History of Fourth-Degree Laceration

I have a patient with a history of fourth-degree perineal laceration in delivery. What code should be used to document her history in a future pregnancy since a C/S may be performed?

Answer

You might consider ICD-10-CM diagnosis code Z87.59, Personal history of other complications of pregnancy, childbirth and the puerperium, to document a history of fourth-degree perineal laceration in delivery.

According to the ICD-10-CM Official Guidelines Chapter 21c4, personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence and therefore may require continued monitoring. Personal history codes may be used in conjunction with follow-up codes and family history codes may be used in conjunction with screening codes to explain the need for a test or procedure.

History codes are also acceptable on any medical record regardless of the reason for visit. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered.