O70 vs O70.1
O70 and O70.1 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 O70.1
perineal laceration involving anal sphincter (O70.2-)
O70
Perineal laceration during delivery
Not billable
- Chapter 15
- Pregnancy, childbirth and the puerperium
- Section
- O60-O77
Use when the record says
- episiotomy extended by laceration
O70.1
Second 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 O70.0, also involving pelvic floor
- Perineal laceration, rupture or tear during delivery as in O70.0, also involving perineal muscles
- Perineal laceration, rupture or tear during delivery as in O70.0, also involving vaginal muscles
Indexed under
- Injury › pelvis, pelvic › complicating delivery
- Rupture, ruptured › pelvic › floor, complicating delivery
- Tear, torn › pelvic › floor, complicating delivery (traumatic)
- Laceration › pelvic › floor › complicating delivery
- Perforation, perforated › pelvic › floor › obstetrical trauma (nontraumatic) (of)
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