I have an OP Note for a vaginal delivery for a patient that had no complications with the pregnancy. In the description of the procedure it states, "…pushed over the course of approximately 2 contractions and brought the fetal vertex to a large crown. There was some difficulty delivering the shoulder and there was noted to be a nuchal arm. The arm was then finally delivered and then the rest of the infant delivered without difficulty."

Since this is not a breech presentation and the arm was not prolapsed, I do not see a code to use to specify this. Would I just overlook this statement since there is not a specific code to address it? There was a first degree laceration, so I will code O70.0 but was wondering if I need another code to specify the nuchal arm.

Thank you,

Rose