Anal sphincter tear comp del, not assoc w third degree lac

This code signifies an isolated injury to the anal sphincter muscle occurring during childbirth, without involvement of the perineal body or external anal sphincter. It represents a tear that is less severe than a third-degree laceration, which involves the external anal sphincter. The injury specifically affects the internal anal sphincter or a superficial portion of the external anal sphincter.

Use this code when documentation clearly indicates an anal sphincter tear complicating delivery, but explicitly states it is not a third-degree laceration. This typically applies to tears classified as 3a (less than 50% external anal sphincter involvement) or 3b (more than 50% external anal sphincter involvement) when the documentation specifies it's not a full third-degree tear, or if only the internal anal sphincter is affected. Documentation should specify the degree of the tear and the structures involved.

• Carefully review the provider's documentation to differentiate between a superficial anal sphincter tear and a full third-degree perineal laceration.
• Do not code this with O70.2- (Third degree perineal laceration) as per the Excludes1 note.
• Ensure the documentation specifies the tear occurred during delivery and the extent of sphincter involvement.