Perineal laceration during delivery, unspecified

This code signifies an uncharacterized tear of the perineum that occurs during the process of childbirth. It indicates that a laceration was sustained in the area between the vagina and anus, but the specific degree or nature of the tear is not documented.

Use this code when documentation confirms a perineal laceration occurred during delivery, but the physician's notes do not specify the degree (e.g., first, second, third, or fourth degree). This code is appropriate when the extent of the tear is unknown or not recorded.

• Avoid using this code if a more specific degree of perineal laceration is documented (e.g., O70.0 for first degree).
• Always review the entire delivery record for details on the laceration's severity.
• This code should be sequenced as a secondary diagnosis following the appropriate code for the outcome of delivery (e.g., Z37.0 for single live birth).