O70.2 vs O70.3
O70.2 and O70.3 can never be reported together. ICD-10-CM declares them mutually exclusive with an Excludes1 note, meaning the two conditions cannot occur in the same patient — so exactly one of them is correct for any given encounter.
The official note, declared on O70.2
perineal laceration involving anal or rectal mucosa (O70.3)
O70.2
Third degree perineal laceration during delivery
Not billable
- Chapter 15
- Pregnancy, childbirth and the puerperium
- Section
- O60-O77
Use when the record says
- Perineal laceration, rupture or tear during delivery as in O70.1, also involving anal sphincter
- Perineal laceration, rupture or tear during delivery as in O70.1, also involving rectovaginal septum
- Perineal laceration, rupture or tear during delivery as in O70.1, also involving sphincter NOS
O70.3
Fourth degree perineal laceration during delivery
Billable
- Chapter 15
- Pregnancy, childbirth and the puerperium
- Section
- O60-O77
Use when the record says
- Perineal laceration, rupture or tear during delivery as in O70.2, also involving anal mucosa
- Perineal laceration, rupture or tear during delivery as in O70.2, also involving rectal mucosa
Indexed under
- Laceration › perineum › female › during delivery › fourth degree
- Tear, torn › anus, anal › complicating delivery › with third degree perineal laceration › with mucosa (traumatic)
- Delivery › complicated › by › laceration › perineum, perineal › fourth degree (childbirth) (labor)
- Delivery › complicated › by › laceration › anus › with third degree laceration › with mucosa (childbirth) (labor)
- Delivery › complicated › by › laceration › rectovaginal › with perineum › with anal or rectal mucosa (childbirth) (labor)
Excludes1 is not always absolute: where two conditions covered by the note are genuinely unrelated, CMS guidance permits reporting both. Document the reasoning rather than assuming it. More on Excludes1 vs Excludes2 · FY2027