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v1.0.0
ICD-10 Guide
ICD-10 CodesN88.1

N88.1

Billable

Old laceration of cervix uteri

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/18/2025

Code Description

ICD-10 N88.1 is a billable code used to indicate a diagnosis of old laceration of cervix uteri.

Key Diagnostic Point:

Old laceration of the cervix uteri refers to a previous injury to the cervical tissue that has healed but may still have implications for the patient's reproductive health. Such lacerations can occur during childbirth, surgical procedures, or trauma. The cervix, being the lower part of the uterus, plays a crucial role in maintaining pregnancy and facilitating childbirth. An old laceration may lead to complications such as cervical incompetence, which can result in premature birth or miscarriage in subsequent pregnancies. Additionally, it may be associated with cervical dysplasia or other noninflammatory disorders of the female genital tract. Proper documentation of the history of the laceration, any associated symptoms, and the impact on reproductive health is essential for accurate coding and treatment planning. The condition is typically diagnosed through pelvic examinations, and any ongoing symptoms should be evaluated to determine if further intervention is necessary.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Requires detailed patient history to establish the old nature of the laceration.
  • Differentiation from acute lacerations or other cervical conditions.
  • Potential association with other gynecological disorders.
  • Need for comprehensive documentation to support the diagnosis.

Audit Risk Factors

  • Inadequate documentation of the history of the laceration.
  • Failure to link the laceration to current symptoms or complications.
  • Misclassification as an acute condition.
  • Lack of follow-up documentation regarding the impact on reproductive health.

Specialty Focus

Medical Specialties

Obstetrics and Gynecology

Documentation Requirements

Detailed history of the laceration, including the cause, treatment, and any ongoing symptoms.

Common Clinical Scenarios

Patients presenting with a history of cervical laceration during childbirth, experiencing complications in subsequent pregnancies.

Billing Considerations

Consideration of the patient's obstetric history and any related gynecological conditions.

Family Medicine

Documentation Requirements

Comprehensive patient history and any relevant gynecological examinations.

Common Clinical Scenarios

Routine gynecological exams where the patient reports a history of cervical laceration.

Billing Considerations

Awareness of the potential long-term effects of cervical lacerations on reproductive health.

Coding Guidelines

Inclusion Criteria

Use N88.1 When
  • According to ICD
  • 10 coding guidelines, N88
  • 1 should be used when there is clear documentation of an old laceration of the cervix that has implications for the patient's health
  • It is important to ensure that the laceration is not currently inflamed or symptomatic, as this would necessitate a different code

Exclusion Criteria

Do NOT use N88.1 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

58120CPT Code

Total abdominal hysterectomy

Clinical Scenario

When a patient with a history of cervical laceration undergoes a hysterectomy due to complications.

Documentation Requirements

Document the indication for surgery, including the history of the laceration.

Specialty Considerations

Obstetricians should ensure that the surgical history is clearly linked to the diagnosis.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of conditions like old lacerations of the cervix, improving the accuracy of patient records and facilitating better management of reproductive health issues.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like old lacerations of the cervix, improving the accuracy of patient records and facilitating better management of reproductive health issues.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of conditions like old lacerations of the cervix, improving the accuracy of patient records and facilitating better management of reproductive health issues.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What is the significance of coding N88.1?

Coding N88.1 is significant as it captures the history of cervical laceration, which can have implications for a patient's reproductive health and future pregnancies. Accurate coding ensures appropriate management and follow-up care.