2025 ICD-10-CM code O70.0
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Obstetric - Complications of labor and delivery (O60-O77) Chapter 15: Pregnancy, childbirth and the puerperium (O00-O9A) Feed
First-degree perineal laceration during delivery.
Modifiers may be applicable depending on the circumstances of the delivery and any additional procedures performed. Consult current modifier guidelines.
Documentation of the perineal laceration's extent is crucial for establishing medical necessity. This ensures accurate billing and appropriate reimbursement.The repair of the laceration, even if minor, supports medical necessity.
Obstetrician or qualified healthcare professional involved in the delivery.
- Chapter 15: Pregnancy, childbirth and the puerperium (O00-O9A)
- O70: Perineal laceration during delivery
In simple words: A small tear in the skin between the vagina and the anus that happened during delivery.
This code signifies a first-degree perineal laceration that occurred during childbirth.A first-degree laceration involves the perineum (the area between the vagina and the anus), specifically the fourchette, labia, skin, or a slight vaginal tear, but does not extend to the muscles or deeper tissues.It includes episiotomies extended by laceration.
Example 1: A patient experiences a minor tear in the perineum during vaginal delivery.The tear is superficial, involving only the skin and not extending to deeper tissues. This would be coded as O70.0., An episiotomy (surgical incision of the perineum) is performed during delivery. A small extension of the incision occurs during the process. This would still be classified as O70.0, as the deeper structures are not involved., During a vaginal delivery, a patient sustains a small tear of the labia minora, extending no deeper. This is also classified as O70.0.
Medical record must clearly document the location and extent of the perineal laceration, confirming that it is a first-degree tear (involving only the fourchette, labia, skin, or a slight vaginal tear) and not extending deeper.Delivery notes should describe the event and a physician's note should validate the assessment of the laceration.
** Accurate coding requires precise documentation of the laceration's extent.Any discrepancy may lead to improper reimbursement.Consult relevant coding guidelines and professional resources for clarification in complex cases.
- Payment Status: Active
- Modifier TC rule: Not applicable for this diagnosis code, as it represents a diagnosis rather than a procedure. Modifiers are applicable only to procedure codes.
- Specialties:Obstetrics and Gynecology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Birthing Center, Ambulatory Surgical Center