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2025 ICD-10-CM code O70

Perineal laceration occurring during childbirth.

Use the most specific code possible based on the depth and extent of the laceration.O70 is used only for maternal records, not for newborn records. If an episiotomy was performed and extended by laceration, code O70 is appropriate.

Medical necessity is established by the presence of a perineal laceration during childbirth that requires repair or management to prevent complications such as infection, pain, and fecal incontinence.

Obstetrician or other qualified healthcare professional delivering the baby and performing any necessary repair.

IMPORTANT:O70.0: First-degree perineal laceration; O70.1: Second-degree perineal laceration; O70.2: Third-degree perineal laceration; O70.3: Fourth-degree perineal laceration.Use additional codes from category Z3A (Weeks of gestation) if the week of pregnancy is known.

In simple words: This code is used when a woman tears the skin and/or muscles between her vagina and anus during childbirth.The tear can range from mild to severe, depending on how deep it goes.

This code encompasses perineal lacerations of varying degrees (first, second, third, and fourth) that occur during the process of childbirth.It includes episiotomies that are extended by laceration.The specific degree of laceration should be further specified using the appropriate subcodes (O70.0-O70.3)based on the extent of tissue involvement.The code excludes obstetric high vaginal laceration alone (O71.4).

Example 1: A patient delivers vaginally and experiences a first-degree perineal laceration (O70.0) involving only the skin and superficial tissues.Repair is performed during the delivery., A patient experiences a second-degree perineal laceration (O70.1) extending into the perineal muscles, requiring repair at the time of delivery., A patient sustains a third-degree perineal laceration (O70.2) involving the anal sphincter muscles, necessitating surgical repair in the postpartum period.

Complete medical record including the history, physical examination findings, documentation of the delivery, the type and extent of the perineal laceration, the method of repair (if performed), and any complications.

** The code O70 is not specific to the type of laceration.Additional codes should be used to specify the degree of the laceration (O70.0-O70.3).

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