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Repair Clitoris to No Qualifier with No Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | U Female Reproductive System |
| Operation | Q Repair |
| Body Part | J Clitoris |
| Approach | 0 Open |
| Device | Z No Device |
| Qualifier | Z No Qualifier |
Operation Definition
Restoring, to the extent possible, a body part to its normal anatomic structure and function
Procedure Overview
Repair procedures in the female reproductive system cover surgeries that restore a body part to its normal structure and function when no other root operation more precisely describes what was done. This is the root operation used when a surgeon closes a laceration, drains a hematoma, or corrects a defect without removing tissue, replacing it with a substitute, or rearranging anatomy in one of the other specific ways ICD-10-PCS defines. It is essentially a catch-all for reconstructive or corrective work on the uterus, ovaries, fallopian tubes, vagina, vulva, or cervix.
Patients encounter these procedures after childbirth trauma, such as suturing a perineal or cervical tear, or following an injury or unintended surgical complication, such as repairing an accidental puncture of the uterus during another operation. Because Repair is a residual category, it is only assigned when the documentation doesn't support a more specific term like Resection, Reposition, or Supplement.
Anatomy & Axis Detail
Clitoris
The clitoris is repaired following traumatic injury, obstetric laceration extending into the clitoral region, or complications from prior genital surgery, with the aim of restoring its normal anatomic structure. Because the clitoris is highly vascular and densely innervated, repair requires meticulous technique to preserve sensory function and avoid excessive scarring, and surgeons document the extent of injury and the layers involved in closure. This body part value is used specifically when the procedure restores clitoral tissue that has been torn or otherwise structurally compromised, as distinct from procedures that remove clitoral tissue, which fall under different root operations. Given the sensitivity of this anatomy, documentation of informed consent and the clinical indication for repair is particularly important.
Approach: Open
Open approach means the surgeon cuts through skin, mucous membrane, or other tissue layers to physically expose the target site to view before performing the procedure. It gives direct visualization and hands-on access, distinguishing it from Percutaneous approaches where instruments pass through a small puncture without exposing the site. Open is typical for procedures needing wide access, such as most laparotomies.
Coding & Documentation
A coder should turn to Repair only after confirming that none of the more specific root operations apply, since PCS coding conventions treat Repair as the default rather than a first choice. The operative note needs to clearly describe suturing, closure, or reconstruction of a defect, along with the exact structure involved (for example, cervix versus vaginal wall) and the surgical approach, whether open, percutaneous endoscopic, or vaginal.
The most common assignment error is defaulting to Repair when the surgeon actually performed a more specific operation, such as reattaching a prolapsed structure to its normal position (Reposition) or reinforcing tissue with mesh (Supplement). Coders also sometimes miss that a repair performed incidentally during a different primary procedure, like repairing a cystotomy during a hysterectomy, may not need separate coding depending on payer and coding guideline rules.