Anal Sphincter Laceration at Vaginal Delivery
Is This Event Coded Accurately?
Linda Brubaker, MD, MS, Catherine S. Bradley, MD, MSCE, Victoria L. Handa, MD,
Holly E. Richter, PhD, MD, Anthony Visco, MD, Morton B. Brown, PhD, and Anne M. Weber,
for the Pelvic Floor Disorders Network
OBJECTIVE: To determine the error rate for discharge
coding of anal sphincter laceration at vaginal delivery in a
cohort of primiparous women.
METHODS: As part of the Childbirth and Pelvic Symp-
toms study performed by the National Institutes of
Health Pelvic Floor Disorders Network, we assessed the
relationship between perineal lacerations and corre-
sponding discharge codes in three groups of primiparous
women: 393 women with anal sphincter laceration after
vaginal delivery, 383 without anal sphincter laceration
after vaginal delivery, and 107 after cesarean delivery
before labor. Discharge codes for perineal lacerations
were compared with data abstracted directly from the
medical record shortly after delivery. Patterns of coding
and coding error rates were described.
RESULTS: The coding error rate varied by delivery group.
Of 393 women with clinically recognized and repaired
anal sphincter lacerations by medical record documen-
tation, 92 (23.4%) were coded incorrectly (four as first- or
second-degree perineal laceration and 88 with no code
for perineal diagnosis or procedure). One (0.3%) of the
383 women who delivered vaginally without clinically
From the Department of Obstetrics and Gynecology, Loyola University Medical
Center, Maywood, Illinois; Department of Obstetrics and Gynecology, University
of Iowa, Iowa City, Iowa; Department of Obstetrics and Gynecology, Johns
Hopkins University, Baltimore, Maryland; Department of Obstetrics and
Gynecology, University of Alabama at Birmingham, Birmingham, Alabama;
Department of Obstetrics and Gynecology, University of North Carolina at
Chapel Hill, Chapel Hill, North Carolina; Department of Biostatistics,
University of Michigan, Ann Arbor, Michigan;. and National Institute of Child
Health and Human Development, Bethesda, Maryland.
Supported by grants from the National Institute of Child Health and Human
Development (U01 HD41249, U10 HD41268, U10 HD41248, U10
HD41250, U10 HD41261, U10 HD41263, U10 HD41269, and U10
HD41267).
Corresponding author: Linda Brubaker, MD, MS, Loyola University Chicago,
2160 South First Avenue, Maywood, IL 60153; e-mail: Lbrubaker@lumc.edu.
Financial Disclosure
The authors have no conflicts of interest relevant to this article.
© 2007 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/07
VOL. 109, NO. 5, MAY 2007
MD, MS,
reported anal sphincter laceration was coded with a
sphincter tear. No women in the cesarean delivery group
had a perineal laceration diagnostic code. Coding errors
were not related to the number of deliveries at each
clinical site.
CONCLUSION: Discharge coding errors are common
after delivery-associated anal sphincter laceration, with
omitted codes representing the largest source of errors.
Before diagnostic coding can be used as a quality mea-
sure of obstetric care, the clinical events of interest must
be appropriately defined and accurately coded.
(Obstet Gynecol 2007;109:1141–5)
LEVEL OF EVIDENCE: II
A nal sphincter lacerations are reported in 5–10% of
deliveries in the United States.1–3 Anal sphincter
lacerations at vaginal delivery have become an indi-
cator for patient safety and quality of care, with
monitoring by the Agency for Healthcare Research
and Quality (AHRQ), a federal agency within the
Department of Health and Human Services that is
charged with supporting health services research to
improve the quality of health care and to promote
evidence-based decision-making.4 Anal sphincter lac-
erations at vaginal delivery, along with rates of vagi-
nal birth after cesarean and inpatient neonatal mor-
tality, are important components for a new core
measure of obstetric care quality adopted by the Joint
Commission on Accreditation of Healthcare Organi-
zations (JCAHO).5 The AHRQ and JCAHO rely on
hospital discharge coding to obtain their data.
In addition to national monitoring of patient
safety and quality of care, studies of anal sphincter
lacerations often use hospital discharge coding to
identify these lacerations and other obstetric events
because of the potential morbidity and subsequent
pelvic floor effect. However, the accuracy of admin-
istrative data sets is imperfect, as reported in studies of
total hip replacement,6 hip fracture,7 acute myocardial
OBSTETRICS & GYNECOLOGY 1141
infarction,8 cardiac bypass,9 and hospital-reported
complications.10 Data based on diagnostic codes may
be less accurate than procedure-based data.6 Coding
accuracy probably varies between institutions; errors
in coding occur as a result of incomplete documenta-
tion of clinical information on the chart, physician
misdiagnosis, or coders’ miscoding or incomplete
coding of diagnoses and procedures.11
Although studies exist that examine the accuracy
of coding for various medical conditions, only one
publication describes the accuracy of discharge cod-
ing for anal sphincter laceration and repair at vaginal
delivery.12 This study reported that discharge coding
was more than 90% sensitive and 97% specific. How-
ever, the study obtained data from a single state, was
limited by a small number of anal sphincter lacera-
tions (n⫽64), and used recoding of hospital charts by
expert coders as the standard for comparison. The
objective of this report was to describe whether
hospital-coded discharge diagnoses of anal sphincter
injury accurately captured perineal lacerations, par-
ticularly anal sphincter injury, using data prospec-
tively collected from a cohort study conducted by the
Pelvic Floor Disorders Network.
MATERIALS AND METHODS
Between September 2002 and September 2004, pri-
miparous women after delivery were enrolled into
one of three groups for an National Institutes of
Health (NIH)–sponsored cohort study to evaluate the
relationship between childbirth and pelvic symptoms.
The three groups included women with clinically
diagnosed anal sphincter laceration (third- or fourth-
degree perineal laceration) and repair after vaginal
delivery (anal sphincter tear group); women without a
clinically diagnosed anal sphincter laceration (no lac-
eration, or first- or second-degree perineal laceration)
after vaginal delivery (vaginal control group); and
women delivered by cesarean without labor (cesarean
control group). This prospective study was conducted
at nine hospitals, including seven university hospitals
and two community hospitals. institutional review
board approval was obtained at all nine hospitals.
To identify the diagnosis of anal sphincter lacer-
ation, trained research nurses examined medical
records, including delivery notes. All but one study
hospital were using paper, not electronic, medical
records during the study period. We defined anal
sphincter laceration as any third- or fourth-degree
perineal laceration diagnosed at delivery. Medical
records were evaluated while patients were hospital-
ized. The clinical record was used as the standard,
because this is the source document for hospital
discharge coding.
This ancillary study to the Childbirth and Pelvic
Symptoms study was designed after primary data
collection from the hospitals had been completed.
Therefore, the administrative discharge coding was
completed by coders who were unaware of this study.
Coders handled any discrepancies between nursing
and physician notes per their usual process without
input from research staff with the Childbirth and
Pelvic Symptoms study. After all participants were
discharged, we collected the hospital discharge codes
from each medical record. We then compared the
coded diagnoses to the clinical record regarding
perineal lacerations, particularly anal sphincter lacer-
ation. Table 1 lists the diagnostic codes used in this
study.
The error rates of coded diagnoses were calcu-
lated using the clinical documentation of anal sphinc-
ter laceration as the standard. With close to 400
subjects per group, the 95% confidence interval (CI)
for the estimates of the error rates is no greater than

Table 1. International Classification of Diseases, 9th Revision, Volumes 1 and 2 Diagnostic Codes
ICD-9 Definition CAPS Definition
First-degree laceration during Perineal laceration, rupture, or tear involving Tear involving vaginal mucosa
delivery (664.01) fourchette, hymen, labia, skin, vagina, or vulva and submucosa
Second-degree laceration during Perineal laceration, rupture, or tear (after episiotomy) Tear involving vaginal mucosa
delivery (664.11) involving the pelvic floor, perineal muscles, or and superficial perineal
vaginal muscles muscles; episiotomy without
extension
Third-degree laceration during Perineal laceration, rupture, or tear (after episiotomy) Tear into or through anal
delivery (664.21) involving the anal sphincter, rectovaginal septum, or sphincter
sphincter
Fourth-degree laceration during Perineal laceration, rupture, or tear (after episiotomy) Tear through anal sphincter and
delivery (664.31) involving the anal sphincter, rectovaginal septum, or anorectal mucosa
sphincter and also the anal or rectal mucosa
ICD-9, International Classification of Diseases, 9th Revision; CAPS, Childbirth and Pelvic Symptoms study.

1142 Brubaker et al Delivery-Associated Sphincter Lacerations OBSTETRICS & GYNECOLOGY

⫾5%. When the estimate is 10% or less, the 95% CI is
no greater than 3%. Confidence intervals were esti-
mated using the binomial distribution.
RESULTS
Diagnostic codes were obtained for 883 of the 907
subjects in the Childbirth and Pelvic Symptoms
study: 393 women who had clinically diagnosed anal
sphincter lacerations (third- or fourth-degree perineal
tears), 383 women in the vaginal control group with-
out clinically diagnosed anal sphincter tears, and 107
women in the cesarean control group. None of the
women in the cesarean control group was coded as
having an anal sphincter tear or any type of perineal
laceration. This group was not used for further
comparisons.
The majority of women with a clinically recog-
nized anal sphincter tear (301 of 393, [76.6%]) had
coding that included either the 664.21 (third degree)
or 664.31 (fourth degree) diagnostic codes for perineal
lacerations (Table 2). An additional four (1.0%) were
coded as either a first- or second-degree perineal
laceration. In the remaining 88 (22.4%) participants,
no diagnostic code for perineal status or procedure
was used. Therefore, the coding error rate for the anal
sphincter tear group was 23.4% (92 of 393). In the
sphincter tear group, the percent of coding errors for
the eight hospitals that recruited more than 30 partic-
ipants ranged from 0% to 62%; the error rate was not
associated with the number of study deliveries. The
one hospital with electronic records had an error rate
of 18%.
Seventy-one of the 383 women in the vaginal
control group were reported to have an intact peri-
neum in the medical record; of these, 19 were coded
as either first- or second-degree tear for an error rate
of 26.8%. The remaining 312 women in the vaginal
control group were classified in the medical record as
having either a first- or second-degree tear. Of these
312, one was coded as having a third- or fourth-
degree tear (0.3%), and 120 did not have any code, for
an error rate of 38.5%.
Eleven subjects had more than one code associ-
Table 2. Coding Error Rate by Each Group of Interest
Third- or fourth-degree laceration coded‡
No third- or fourth-degree laceration coded
Error rate (95% confidence interval)
* Third- or fourth-degree laceration recorded in medical record.
†
No laceration, first- or second-degree laceration in medical record.
‡
That is, coded 664.21 or 664.31.
VOL. 109, NO. 5, MAY 2007
ated with perineal laceration status. Duplicate coding
occurred in six of 393 (1.5%) of the anal sphincter tear
group and five of 383 (1.2%) of the vaginal control
group. In the anal sphincter tear group, five subjects
had codes for a third-degree tear (664.21) as well as a
code for a first- or second-degree tear (664.01 or
664.11); one subject had codes for both third- and
fourth-degree tears. In the vaginal control group, five
subjects had codes for both first- and second-degree
tears (664.01 and 664.11). In all cases, the higher code
was used to classify the subject for data analyses.
The mean number of discharge diagnostic codes
by site ranged from 2.9 to 7.8 for women with anal
sphincter laceration compared with 2.5 to 7.2 for
women without anal sphincter laceration. Coding
error was not associated with the number of deliveries
at each institution, or the number of hospital dis-
charge codes for each individual.
DISCUSSION
Administrative discharge codes are increasingly used
in health services research as a means for monitoring
quality at local and national levels.4,5,13 With respect to
pelvic floor disorders research, these databases can be
used to identify a large representative sample of
patients of interest (eg, patients with anal sphincter
tear).14 Patient recall has been used in some studies of
obstetric outcomes, although recall of obstetric events
is poor,15 especially for anal sphincter injury. We
found that nearly one of four hospital discharges
associated with a third- or fourth-degree anal sphinc-
ter laceration was undercoded, suggesting that admin-
istrative data underestimates the occurrence of these
sphincter lacerations, which limit the usefulness of
these data as a quality-of-care metric.
Past studies have found other obstetric conditions
are also inaccurately coded. One study reviewed
medical records and administrative data related to
indications for elective primary cesarean delivery in a
single hospital and reported an overall sensitivity of
73% and specificity of 98.1% using International
Classification of Diseases, 9th Revision–Clinical
Modification diagnosis codes.16 Other studies that
Sphincter Tear Group* Vaginal Control Group†
301 1
92 382
23.4% (19.5–28.0%) 0.3% (0.06–1.5%)
Brubaker et al Delivery-Associated Sphincter Lacerations 1143
reviewed medical charts for cases identified through
specific diagnosis codes have found that the codes’
positive predictive values are low. In a study of
discharge coding and uterine rupture, the positive
predictive value of uterine rupture discharge codes
was 39.8%.17 Discharge codes were not specific for
uterine rupture and were not applied consistently
over the 7 years studied. The positive predictive value
of discharge codes for other pregnancy-related com-
plications has also been reported to be low, for
instance, 39% in the case of venous thromboembo-
lism and 54% for preeclampsia, and to vary wide-
ly.18,19 In this study, we have not reported predictive
values for anal sphincter laceration discharge codes,
because predictive values vary by prevalence, and the
prevalence of anal sphincter tears in our study was
artificially high by design.
Beyond obstetrics, inaccurate coding has also
been demonstrated in medical and surgical complica-
tion reporting.20 In contrast to our results, errors
occurred frequently in coding complications for
which there was no evidence in the medical record in
30% of medical admissions and 19% of surgical
admissions.
Romano et al12 recently published the only other
study investigating the accuracy of diagnosis and
procedure codes for anal sphincter lacerations. These
investigators reported high specificity and sensitivity.
This study sampled cases from 52 hospitals in Cali-
fornia, selected by a complex stratified random sam-
pling procedure, and studied patient records and
discharge data at each hospital over a 1–2-year pe-
riod. Using two International Classification of Dis-
eases, 9th Revision-Clinical Modification diagnosis
codes (664.3x, any fourth-degree perineal laceration;
and 664.2x, any third-degree perineal laceration) as
well as one procedure code (75.62), they identified 64
cases of anal sphincter laceration; coding experts
compared hospital discharge data with the medical
records as the standard. Discrepant cases were then
reviewed by two investigators. Hospital discharge
data had a weighted sensitivity of 94% (90% CI,
83–98%) and specificity greater than 97% for anal
sphincter laceration. These results led them to con-
clude that discharge data are an adequate substitute
for medical record review in estimating the occur-
rence of anal sphincter lacerations. However, the
error rate was not reported. The very wide CI is due
to the small sample size; the lower bound of their CI
is similar to the rate that was observed in our study.
Our study’s strengths include the multicenter,
multistate design and abstraction of data directly from
the medical record. Due to the parent study (the
1144 Brubaker et al Delivery-Associated Sphincter Lacerations
Childbirth and Pelvic Symptoms study) design, we
were able to include a large number of cases of third-
or fourth-degree anal sphincter laceration, allowing us
to estimate more precisely the coding error rates for
the most clinically relevant patients. However, our
results may not be generalizable to all hospitals
providing obstetric care. It is possible that our results
differ from other studies because of regional differ-
ences in coding training. As with many case-based
quality-of-care studies, we used the medical record as
a standard; however, it is possible that the medical
record is also inaccurate with regard to anal sphincter
lacerations and that some events may not be recorded
in this manner or may have been missed by our
abstraction process.
The occurrence of anal sphincter lacerations is
one of the core quality indicators reviewed by AHRQ
and JCAHO.4,5 Such quality indicators are typically
abstracted from discharge codes without reviewing
the clinical record. However, apparent differences in
the rates of anal sphincter laceration could represent
different coding practices between institutions, rather
than a true difference in lacerations. Our data suggest
that hospital discharge coding may underestimate the
true occurrence of anal sphincter lacerations, al-
though the coding error rate varied widely, from 0%
to 62%, among the eight hospitals in our study.
The Joint Commission defines a third-degree
perineal laceration as “a rupture or tear in the peri-
neum involving the anal sphincter and rectovaginal
septum”; a fourth-degree laceration is “a rupture or
tear involving anal sphincter, rectovaginal septum
and mucosa” (presumably anal or anorectal mucosa).
These definitions may be consistent with definitions
used by obstetric providers. Clinical terms such as
“partial third degree lacerations” may not fall into
such a coding scheme, leaving coding teams with
uncertainty as to the correct diagnostic code. We
suggest that recording of perineal status might be
improved by implementing standardized definitions
to describe the perineum after delivery.
In conclusion, our results call into question the
validity of using hospital discharge data for the iden-
tification or monitoring of anal sphincter lacerations,
because these data may underestimate the true occur-
rence of this complication. The importance of identi-
fying anal sphincter tears has been clearly demon-
strated, because these new mothers have higher rates
of fecal and flatal incontinence.21 In keeping with the
goal to recognize and reduce these adverse events, it
is important to minimize discharge coding errors.
Hospitals may have artificially low anal sphincter
laceration rates secondary to coding errors, leading to
OBSTETRICS & GYNECOLOGY
erroneously favorable comparisons with institutions
with more accurate coding practices.
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