Laceration without foreign body of vagina and vulva, sequela

This code describes a past injury involving a tear or cut to the external female genitalia (vulva) or the birth canal (vagina) that did not involve any foreign material embedded in the wound. It is used when the patient is presenting for treatment of a complication or residual effect directly resulting from that original laceration, rather than the acute injury itself.

Apply this code when documenting conditions such as chronic pain, scarring, adhesions, or functional impairment (e.g., dyspareunia, incontinence) that are directly attributable to a previously sustained laceration of the vagina or vulva. This code is appropriate for follow-up care or management of long-term sequelae after the initial healing phase of the laceration.

• Always use this "S" code as a secondary diagnosis, following the code for the specific sequela being treated (e.g., chronic pain, scar formation).
• Ensure documentation clearly links the current condition to the previous laceration of the vagina or vulva.
• The "S" seventh character indicates sequela, meaning the patient is being seen for a complication or residual effect of the original injury.