P046 – Repair of fourth degree tear or episiotomy extension
OHIP Plastic Surgery Code — OBSTETRICS · Schedule of Benefits
Repair of fourth degree tear or episiotomy extension, must include repair of rectal mucosa, perianal sphincter and perineum.
When to Use
- Use P046 when a fourth-degree obstetric laceration or episiotomy extension requires formal repair involving the rectal mucosa, the internal and external anal sphincters, and the perineal body.
- Use this code specifically when the surgical repair extends beyond the perineum into the anal canal, distinguishing it from third-degree repairs (P045) or standard second-degree repairs included in P006/P020.
Common Pitfalls
- Billing P046 for a third-degree tear; third-degree repairs must be billed under P045, while anything less than third-degree is considered part of the global delivery fee (P006/P020).
- Failing to explicitly document the involvement of the rectal mucosa in the operative note, which is a mandatory requirement for P046 and a common trigger for audit rejection.
- Submitting P046 as a non-OB/GYN specialist without preparing for manual review, as the Ministry flags these claims for verification of the surgical nature of the repair.
Billing Tips
- Ensure the operative report clearly describes the anatomical layers repaired (rectal mucosa, sphincter complex, and perineum) to satisfy the documentation requirements for P046 versus the lesser P045.
- Always append the appropriate after-hours premium (E409 or E410) if the delivery and subsequent repair commence during the specified night or weekend windows, as these are eligible add-ons for this procedure.
Effective: April 1, 2025
K. Obstetrics
OBSTETRICS
Surgical
Obstetrics, Female Genital Surgical Procedures
The procedure must include repair of rectal mucosa, perianal sphincter and perineum.
Female
1. Repair of a tear or episiotomy extension that does not extend into the perianal sphincter (third degree) is included in the labour and delivery fee (P006 and P020) and does not constitute P045 or P046.
2. Repair of the superficial transverse perineal muscle constitutes a repair of a second degree tear or episiotomy extension and does not constitute P045 or P046.
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