2025 ICD-10-CM code O70.23
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Obstetrics - Complications of labor and delivery (O60-O77) Chapter 15: Pregnancy, childbirth and the puerperium (O00-O9A) Feed
Third-degree perineal laceration during delivery, involving both the external and internal anal sphincters.
Modifiers are not applicable to ICD-10 codes.Modifiers are used with CPT and HCPCS codes to add additional context to the procedure or service performed.
The medical necessity for coding O70.23 is established by the presence of a third-degree perineal laceration during childbirth.The severity of the tear warrants documentation and coding to reflect the extent of injury and the need for potential surgical repair and subsequent management.
The obstetrician or other qualified healthcare professional delivering the baby is responsible for diagnosing and treating the perineal laceration. This may involve surgical repair of the laceration.
- Chapter 15: Pregnancy, childbirth and the puerperium (O00-O9A)
- O70.23 is part of the broader category O70 (Perineal laceration during delivery), which falls under the larger chapter O60-O77 (Complications of labor and delivery).
In simple words: This code describes a serious tear in the area between the vagina and anus that happened during childbirth.The tear is severe and affects the muscles that control bowel movements.
This code signifies a third-degree perineal laceration that occurred during childbirth.The laceration extends through the perineal muscles and involves a tear in both the external anal sphincter (EAS) and the internal anal sphincter (IAS). This is a severe perineal tear requiring more extensive repair.
Example 1: A 30-year-old primipara (first-time mother) experiences a third-degree perineal laceration during vaginal delivery. The laceration involves both the external and internal anal sphincters, requiring surgical repair. Code O70.23 is applied., A 25-year-old multipara experiences a third-degree perineal laceration during a precipitous (rapid) vaginal delivery. The laceration is extensive, requiring immediate surgical repair to prevent complications.Code O70.23 is applied along with codes reflecting the repair procedure., A 35-year-old patient with a history of prior perineal trauma undergoes a vaginal delivery. During delivery, a third-degree perineal laceration occurs, requiring surgical repair in the operating room. Code O70.23 is used to document the laceration, alongside codes that specify the surgical repair.
Detailed documentation should include the degree of the laceration (IIIc), extent of involvement of the anal sphincters, the method of delivery, and details of the repair (if performed).Operator notes and the patient's chart should clearly reflect the diagnosis.
** This code should only be used for maternal records.It should not be used for newborn records.Always verify coding accuracy with the most current ICD-10-CM guidelines.
- Revenue Code: Revenue codes will vary based on the specific services provided and payer requirements.Consult your payer's guidelines for appropriate revenue code assignments.
- RVU: RVUs are not directly associated with ICD-10 codes. RVUs are used for CPT codes and will vary by location, payer, and other factors.Consult your payer's guidelines for relevant information.
- Global Days: The global surgical period does not apply to ICD-10 codes; it's specific to CPT procedure codes.
- Payment Status: Active
- Modifier TC rule: Not applicable to ICD-10 codes.
- Fee Schedule: Not applicable to ICD-10 codes.Fee schedules relate to CPT and HCPCS codes.
- Specialties:Obstetrics and Gynecology
- Place of Service:Inpatient Hospital, Birthing Center, Ambulatory Surgical Center