2025 ICD-10-CM code O70.4
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Obstetrics - Complications of labor and delivery (O60-O77) Pregnancy, childbirth and the puerperium (O00-O9A) Feed
Anal sphincter tear complicating delivery, not associated with a third-degree laceration.
The medical necessity for this code is established by the presence of an anal sphincter tear during delivery that requires assessment and treatment.The tear may necessitate surgical repair or other interventions. Accurate coding is crucial for appropriate reimbursement and to reflect the complexity of care provided.
Obstetricians and other healthcare professionals involved in delivering babies are responsible for diagnosing and managing this condition.This includes conducting thorough perineal examinations to assess the extent of the injury and providing appropriate treatment.
In simple words: This code describes a tear in the muscle around the anus that happens during childbirth. This tear is not as severe as other types of tears that happen during delivery.
This ICD-10-CM code signifies an anal sphincter tear that occurs during childbirth.The tear is specifically not associated with a third-degree perineal laceration, which involves more extensive damage.This code is used for maternal records only, never for newborn records.It's crucial to differentiate this from other perineal lacerations based on the extent of the injury.The condition is coded according to the severity of the tear, and additional codes might be necessary to specify the gestational week.
Example 1: A 25-year-old woman experiences an anal sphincter tear during a vaginal delivery.A thorough examination reveals that the tear is limited to the anal sphincter and doesn't extend to the rectal mucosa, therefore this code is appropriate., A 30-year-old patient delivers vaginally and develops an anal sphincter tear during the delivery process. Post-delivery assessment reveals that only the anal sphincter muscle is affected, and no third-degree tear exists. Documentation supports this., A 35-year-old patient undergoes a vaginal delivery, resulting in an anal sphincter tear. The obstetrician documents the injury as being confined to the anal sphincter muscle, without any further extension to the rectal lining.No other significant injuries are noted.
Detailed documentation of the perineal examination findings, including the extent of the tear and any associated injuries, is necessary. The documentation should confirm that the injury is limited to the anal sphincter and does not involve the rectal mucosa (a third-degree tear).Gestational age at delivery should also be documented.
** Accurate assessment and documentation of the extent of the perineal laceration are crucial for proper coding.Differentiation between first, second, third, and fourth-degree lacerations is critical.This code excludes anal sphincter tears associated with third-degree lacerations.
- Payment Status: Active
- Specialties:Obstetrics, Gynecology, Colorectal Surgery
- Place of Service:Inpatient Hospital, Birthing Center, Ambulatory Surgical Center