Second degree perineal laceration during delivery

This code signifies a second-degree tear of the perineum that occurs during childbirth. This type of laceration involves the perineal muscles but does not extend into the anal sphincter. It is a common obstetric injury requiring repair.

Assign this code when documentation clearly states a second-degree perineal laceration was sustained during a vaginal delivery. Look for terms like "second-degree tear," "perineal muscle involvement," or specific descriptions of the tear's depth not involving the anal sphincter.

• Differentiate carefully between first, second, third, and fourth-degree lacerations based on documentation of muscle and sphincter involvement.
• Refer to the Excludes1 note; if the anal sphincter is involved, a code from O70.2- must be used instead.
• Ensure the documentation specifies that the laceration occurred during delivery, not pre-existing or post-delivery.