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2025 ICD-10-CM code O70.20

Third-degree perineal laceration during delivery, unspecified.

This code should only be used on the maternal record, not the newborn's record.An additional code from category Z3A, Weeks of gestation, should be used to specify the week of pregnancy if known.

Repair of the third-degree perineal laceration is medically necessary to restore anatomical integrity and prevent complications such as infection, incontinence, and pain.

Obstetricians and other healthcare professionals attending to vaginal deliveries are responsible for identifying, documenting, and managing perineal lacerations.

In simple words: This code indicates a tear in the area between the vagina and anus during childbirth, which goes through the skin and muscles and involves the anal sphincter muscle.

This code describes a third-degree perineal laceration sustained during delivery.A third-degree laceration extends through the skin and vaginal mucosa, the perineal muscles, and the anal sphincter.

Example 1: A woman delivers vaginally, and during the delivery process, she sustains a tear extending through the vaginal mucosa, perineal muscles, and the anal sphincter. This is diagnosed as a third-degree perineal laceration and coded as O70.20., A patient who had a forceps-assisted vaginal delivery is later found to have a third-degree perineal laceration during postpartum examination. The appropriate code is O70.20., Following a vaginal birth, a woman experiences fecal incontinence. Upon examination, it's determined that she has a previously undiagnosed third-degree perineal laceration.The diagnosis is O70.20.

Documentation should clearly describe the extent of the laceration, including involvement of the anal sphincter.Associated signs and symptoms, such as bleeding or pain, should also be documented.

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