First degree perineal laceration during delivery

This code represents a superficial tear of the perineal skin or vaginal mucosa that occurs during childbirth, but does not involve the underlying muscle. It is the least severe type of perineal trauma, often requiring minimal or no repair.

This code is appropriate when documentation specifies a first-degree laceration of the perineum or vagina during a delivery encounter. The physician's notes should clearly indicate the depth of the tear, explicitly stating it is superficial and does not extend to the perineal muscles.

• Ensure the documentation explicitly states "first degree" and specifies the perineum or vagina as the site of laceration.
• Do not use this code if the laceration involves the perineal muscles (second degree) or anal sphincter (third or fourth degree).
• Sequence this code as a secondary diagnosis following the code for the outcome of delivery (e.g., Z37.0 for single live birth).