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Division Perineum, Female to No Qualifier with No Device, External Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | W Anatomical Regions, General |
| Operation | 8 Division |
| Body Part | N Perineum, Female |
| Approach | X External |
| Device | Z No Device |
| Qualifier | Z No Qualifier |
Operation Definition
Cutting into a body part, without draining fluids and/or gases from the body part, in order to separate or transect a body part
Procedure Overview
Division procedures involve cutting into a general body region to separate or transect tissue, without draining any fluid or gas in the process. In this body system, that typically means cutting through tissue planes or bands in an area like the abdominal wall, back, or pelvic region to free up structures, release a contracture, or separate tissue that has become abnormally connected.
These procedures are performed to restore normal mobility or anatomy, such as releasing scar tissue that is pulling on surrounding structures, or cutting a band that is causing pain or restricting movement. The defining feature is that the cutting itself is the entire purpose of the procedure - nothing is removed, repaired, or drained.
Anatomy & Axis Detail
Perineum, Female
Division of the female perineum involves cutting through the perineal body and its underlying musculature without removing tissue, most classically performed as an episiotomy to enlarge the vaginal outlet during childbirth or to release scar tissue causing perineal contracture. Because the perineal body is a compact junction of muscle and fascia between the vagina and rectum, even a limited incision here affects the support structures for both organs, which is why the depth and direction of the cut - midline versus mediolateral - are clinically significant and typically documented. This code applies specifically when the intent is to free or separate tissue without objective of repair; if the same incision is made specifically to reach another structure for a different procedure, it is not coded separately as Division.
Approach: External
External approach applies to procedures performed directly on the skin or mucous membrane, or on an accessible body surface, without any instrumentation passing through a puncture or orifice. It covers things like manual reduction of a fracture or excision of a skin lesion. It differs from Via Natural or Artificial Opening in that no internal passage is entered at all, only the exposed surface.
Coding & Documentation
A coder selects Division when the documentation describes cutting through a body part purely to separate it into two portions or free it from an adjacent structure, with no removal of tissue and no fluid or gas released as part of the same act. The note should make clear that transection or separation, not extraction or drainage, was the surgeon's objective.
The most common error is confusing a cutting motion that happens to release trapped fluid or gas with true Division, when releasing fluid or gas during the same act actually reclassifies the procedure as Drainage. Coders also sometimes apply Division when tissue was actually cut and then removed, which belongs under Excision or Resection instead.