ICD code O70.0 – First degree perineal laceration during delivery

Key takeaways

O70.0 is a billable ICD-10-CM code for first degree perineal laceration during delivery, valid for FY2026 with no descriptor changes.

First degree tears involve the perineal skin, labia and vaginal mucosa only, with no muscle involvement. Any muscle damage moves the code to O70.1 or higher.

O70 includes episiotomy extended by laceration, so an extended episiotomy is coded by the resulting laceration degree. No Excludes1 note applies to episiotomy.

When the laceration is the only complication, list O70.0 first and add a Z37 outcome-of-delivery code. O80 cannot be reported once a complication is coded.

Repair by the delivering provider is included in 59400 and 59409. CPT 59300 applies only when a different provider performs the repair.

ICD-10 Code O70.0: definition, validity, and key attributes

ICD-10 Code O70.0 is a billable, valid ICD-10-CM diagnosis code with the official descriptor “First degree perineal laceration during delivery.” It covers a slight tear of the perineal skin, fourchette, labia or vaginal mucosa, with no perineal muscle involved. The code sits in Chapter 15 (Pregnancy, Childbirth and the Puerperium), in the O60-O77 block for complications of labor and delivery. The CDC/NCHS ICD-10-CM web tool confirms O70.0 as active for FY2026 with no tabular revisions.

What O70.0 covers: clinical definition and anatomy

A first degree perineal laceration during delivery involves the fourchette, perineal skin, and vaginal mucosa only. No perineal muscle or fascia is disrupted. That anatomical boundary is the coding line. Once the perineal body musculature, the anal sphincter or any deeper structure is involved, the tear is no longer first degree.

The American College of Obstetricians and Gynecologists (ACOG) classifies perineal tears into four grades. O70.0 maps to Grade I. The clinical criteria for Grade I include superficial injury that may or may not require suturing. Many first degree tears heal without repair. A missing repair note does not make the tear non-billable, but the delivery note must still state the degree explicitly.

• Structures involved in O70.0: fourchette, labia, vulva, perineal skin and vaginal mucosa, per the tabular inclusion terms
• Structures NOT involved (first degree): perineal body muscle, external anal sphincter, rectal mucosa
• Repair needed: often not required; when performed, typically single-layer interrupted suture
• Clinical synonym: Grade I perineal tear; first-degree tear during delivery

O70.0 code hierarchy: parent category and sibling codes

The O70 parent category covers all degrees of perineal laceration during delivery. ICD-10 Code O70.0 is the least severe child code. Knowing where O70.0 sits in the hierarchy prevents the common error of assigning the non-specific O70.9 when the degree is documented. Other Chapter 15 categories follow the same layout in our code library for coders.

The specific third degree subcodes (O70.21-O70.23) depend on the clinician documenting how much of the anal sphincter is torn. When the delivery note says “third degree” without sphincter detail, assign O70.20, and query the provider to reach O70.21-O70.23. A sphincter tear with no third degree perineal laceration takes O70.4 instead. The CMS ICD-10 codes guidance reinforces that specificity drives code selection when subcodes exist.

Includes and Excludes1 notes for ICD-10 Code O70.0

The O70 parent category carries notation that governs every child code, including O70.0. Two notes matter most: the Includes note for an episiotomy extended by laceration, and the Excludes1 note for a high vaginal laceration alone.

Includes note

O70 includes “episiotomy extended by laceration.” A laceration that extends an episiotomy is therefore coded O70.x by its degree, so a first degree extension takes O70.0. The O70.0 inclusion terms also cover slight tears and tears involving the fourchette, labia, skin, vagina or vulva.

Excludes1: high vaginal laceration alone

O70 carries one Excludes1 note: obstetric high vaginal laceration alone (O71.4). When the only injury is a high vaginal laceration with no perineal tear, code O71.4 instead of any O70 code. There is no Excludes1 note for episiotomy.

Concurrent vaginal or cervical lacerations

A cervical laceration (O71.3) at the same delivery may be coded alongside O70.0, because the cervix is a separate site. O71.4 works differently. It describes a high vaginal laceration alone, so it does not apply when a perineal laceration is also present. Document each injury site clearly in the delivery note so the coder can assign every code without querying the provider.

How to document a first degree perineal laceration for O70.0

The delivery note must provide enough specificity for a coder to assign O70.0 without a provider query. Structured delivery note templates cut the number of provider queries. A note that says only “perineal laceration repaired” is not codeable to a specific degree.

• Degree stated explicitly: “first degree laceration” or “Grade I perineal tear,” not “minor tear” or “small laceration”
• Anatomical structures described: confirms involvement of skin and mucosa, with no muscle involvement noted
• Repair documented or absence of repair noted: “laceration repaired with single-layer interrupted suture” or “laceration left to heal without repair per patient preference”
• Delivery route confirmed: vaginal delivery (spontaneous or operative). The note must confirm perineal laceration occurred during delivery, not postpartum
• Provider signature: attending obstetrician or qualified provider signature on the delivery note

When repair is performed by a resident and supervised by an attending, document the supervising physician’s name and role. Some payers require the attending’s signature even when the resident performed the procedure. Missing this detail is a recurring cause of claim adjustment, not outright denial, but it delays payment cycles.

Paired CPT codes and perineal repair coding for O70.0

ICD-10 Code O70.0 appears on claims alongside procedure codes for the vaginal delivery and, when repair is performed, a repair CPT code. Repair by the delivering provider is included in the delivery code, so it cannot be billed separately. An obstetric superbill that pre-populates common delivery code sets helps prevent unbundling errors at the point of service documentation.

CPT 59300 is separately billable when repair is performed by a provider other than the one who delivered the baby. Verify current NCCI (National Correct Coding Initiative) edits before billing CPT 59300 alongside a delivery code, because CMS updates the edit pairs quarterly. Pabau, the practice software we build, connects to Claim.MD, a medical claims clearinghouse, so US practices can submit and track electronic claims. Check NCCI edits against the current CMS tables before submitting.

O70.0 vs. O70.1 vs. O70.2: choosing the right degree code

The correct degree code depends on the anatomical extent documented by the treating clinician. Coders must not infer degree from the repair technique or operative time. The provider’s stated degree determines the code, and the chart below shows which tissue layer moves the tear up each step.

The AAPC ICD-10-CM code lookup includes the full O70 family with hierarchy navigation useful for confirming subcode specificity at the point of coding.

Coding multiple perineal lacerations of different degrees

A patient can sustain more than one laceration during the same delivery. When the perineal tears are contiguous and represent a single wound that has extended, code the highest degree present. That approach is consistent with AHA Coding Clinic guidance.

An injury at a separate, non-perineal site is a different case. A cervical laceration documented alongside a first degree perineal tear takes its own code, so the claim carries both O70.0 and O71.3.

• Contiguous wound, multiple degrees: code the highest degree only (e.g., O70.1, not O70.0 + O70.1)
• Separate non-perineal site: code that injury with its own O71 code, such as O71.3 for the cervix
• Provider query required when: documentation says “multiple perineal lacerations” without specifying the degree of each

When the documentation is unclear, query the provider and check the current AHA Coding Clinic edition for obstetric scenarios.

Episiotomy vs. perineal laceration: coding pitfalls for O70.0

An episiotomy is a planned surgical incision of the perineum to enlarge the vaginal opening. A perineal laceration is a spontaneous tear. When an episiotomy extends into a laceration, the O70 Includes note applies, so you code the resulting laceration degree. An uncomplicated episiotomy has no O70 diagnosis code at all.

Documentation language matters. “Mediolateral episiotomy repaired” codes differently from “first degree perineal tear repaired.” Coders who see “vaginal repair” without further detail should query before coding. The answer decides whether the claim carries an O70 laceration code at all.

Payer requirements for perineal laceration repair

First degree perineal laceration repair is generally not separately billable when the delivering provider performs it. That repair is included in the delivery code, whether the claim uses the global 59400 or the delivery-only 59409. Separate billing of repair CPT codes without a documented different-provider scenario is a common audit trigger. Maintaining medical billing compliance practices around obstetric global packages reduces this risk.

For Medicaid, bundling policies vary by state. Some state Medicaid programs allow separate billing of CPT 59300 when a provider other than the delivering physician performs the repair. They usually require an attestation or modifier to support the different-provider claim. Verify the relevant state Medicaid fee schedule annually, as these rules update with each fiscal year.

• Medicare: repair by the delivering provider is included in the delivery code; separate billing triggers review without a documented different-provider scenario
• Medicaid: state-specific; some allow separate repair billing for different providers with appropriate documentation
• Commercial payers: policy varies; confirm in the provider contract or with the payer’s provider services line before billing repair separately
• Timely filing: O70.0 claims are subject to standard filing windows (Medicare: 12 months from service date; commercial: check contract)

Common claim denial reasons for O70.0 and how to avoid them

Obstetric claims carrying ICD-10 Code O70.0 are commonly denied for bundling conflicts, missing degree documentation, or episiotomy and laceration confusion. Each denial type has a defined appeal path. Pabau’s claims software for practices helps teams submit and track these claims, so a denial surfaces quickly. Structured denial management workflows handle the ones that come back.

Sequencing matters on delivery claims. Chapter 15 codes take sequencing priority, so when the laceration is the only complication, O70.0 is listed first. Z37.x follows as the additional outcome-of-delivery code, because Z37 codes are never first-listed. O80 cannot be used here, since it applies only to a delivery with no complication coded. A clean claim submission carries O70.0 first and Z37.x after it.

How Pabau supports clean O70.0 delivery claims

A delivery claim is usually assembled by hand from the delivery note: the laceration degree, the Z37 outcome code and the delivery CPT. An error in any of them only surfaces when the payer denies the claim, often weeks later.

In Pabau, the delivery documentation and the codes your team assigns sit on the same patient record, and the claim is pre-filled from that record. Through the Claim.MD integration, US practices check eligibility, submit the claim electronically and track its status until the remittance posts.

Your billing team still chooses and sequences the codes. Pabau keeps every claim’s status in view, so a denied O70.0 claim is corrected and resubmitted well inside the filing window.

Submit and track delivery claims with Pabau

Pabau pulls the delivery record into a pre-filled claim and sends it through Claim.MD. Your team can then track each claim and correct denials quickly.

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Conclusion

O70.0 is the right code only when the delivery note names a first degree tear and records no muscle involvement. Build that wording into your delivery note template, and fewer O70.0 claims will need a provider query.

The rules that trip these claims are narrow. An extended episiotomy takes the laceration’s degree, and repair by the delivering provider stays inside the delivery code. O70.0 goes first, with Z37.x after it. Get those three right and a payer has little left to question.

Pabau helps your team submit and track these claims, so a denial is caught while the filing window is still open. Book a demo to see how Pabau handles delivery claims from submission to payment.

Continue your research

Dealing with frequent claim rejections on delivery codes? Denial codes in medical billing explains the most common CARC denial codes and how to respond to each.

Submitting US claims electronically? The Claim.MD clearinghouse guide explains how the clearinghouse fits into a US practice’s claims workflow.

Coding another labor and delivery complication? ICD-10 Code O75.0 covers maternal distress during labor and delivery.

Documenting slow labor progress? ICD-10 Code O62.1 covers secondary uterine inertia and how to document it.

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