In simple words: This code describes a tear in the area between the vagina and anus that happened during childbirth. The doctor doesn't know exactly how severe the tear is.

This code is used to classify perineal lacerations that occur during childbirth when the degree of laceration is unknown or unspecified.The perineum is the area between the vagina and the anus. A laceration is a tear in this tissue.This code encompasses tears that may involve the skin, muscles, and/or anal sphincter, but the specific degree of involvement is not specified.This code should only be used in maternal records, not newborn records.

Example 1: A 32-year-old woman delivers vaginally.A postpartum examination reveals a perineal laceration, but the exact degree is not documented., A 28-year-old woman experiences a perineal tear during a spontaneous vaginal delivery. The obstetrician notes the tear but does not specify the degree in the immediate postpartum record., A 40-year-old woman undergoes a forceps delivery, resulting in an unspecified perineal laceration requiring repair. The level of the tear is not clearly documented in the operative notes.

Complete obstetric history, detailed description of the delivery, documentation of any perineal trauma including location, extent, and repair performed.

** Always verify the code's applicability and accuracy with the most up-to-date coding guidelines and payer-specific rules.This code should only be utilized when the degree of perineal laceration cannot be definitively determined.