icd 10 code for grade 3 liver laceration

What is a Grade 3 liver laceration?

A grade III laceration is characterized by a laceration that is > 3 cm of parenchymal depth, a subcapsular hematoma that is > 50% surface area of ruptured subcapsular or parenchymal hematoma, and an intraparenchymal hematoma that is > 10 cm or expanding.

Is a Grade 3 liver laceration minor or moderate?

The WSES Classification divides Hepatic Injuries into three classes: Minor (WSES grade I). Moderate (WSES grade II). Severe (WSES grade III and IV).Oct 10, 2016

What is a grade 4 liver laceration?

grade IV. laceration: parenchymal disruption involving 25-75% hepatic lobe or involves 1-3 Couinaud segments. vascular injury with active bleeding breaching the liver parenchyma into the peritoneum.Sep 20, 2021

What is a moderate liver laceration?

They are as follow: Minor: Laceration involving capsule only or without significant involvement of hepatic parenchyma (less than one centimeter deep) Moderate: Laceration involving parenchyma but without major disruption of parenchyma (less than 10 centimeters long and less than three centimeters deep)Jul 1, 2021

What is the ICD 10 code for liver injury?

Unspecified injury of liver, initial encounter S36. 119A is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.

What are the grades of liver injury?

Table 1GradeTypeInjury descriptionVLacerationParenchymal disruption involving >75% of hepatic lobe or >3 Couinaud's segments within a single lobeVascularJuxtahepatic venous injuries (i.e., retrohepatic vena cava/central major hepatic veins)VIVascularHepatic avulsion8 more rows

What is a Grade 3 spleen laceration?

Grade 3 is hematoma of more than 50% of the subcapsular surface area or if the hematoma is known to be expanding over time, if the hematoma has ruptured, intraparenchymal hematoma either more than 5 cm or known to be expanding, or capsule laceration more than 3 cm in depth and/or involving a trabecular blood vessel.

What is a liver laceration?

Liver laceration is a physical injury to the liver, the organ located below the right ribs. It is the most commonly injured organ in abdominal trauma from both blunt and penetrating sources. A liver laceration is a tear in the liver tissue. Liver lacerations range in severity from mild to very severe or fatal.

How is liver laceration diagnosed?

How is a liver or spleen laceration diagnosed?X-ray, ultrasound, CT, or MRI pictures may show a hole, cut, or tear in your liver or spleen. ... Blood tests check your blood cell levels and liver function.A diagnostic laparoscopy looks for damage to your liver or spleen and bleeding in your abdomen.Apr 4, 2022

What is a Grade 5 liver laceration?

Grade V: laceration: parenchymal disruption involving >75% of hepatic lobe or >3 Couinaud segments within a single lobe; vascular: juxtahepatic venous injuries (ie, retrohepatic vena cava/central major hepatic veins).Jun 8, 2017

What causes laceration of the liver?

Because of its size, the liver is the most easily injured abdominal organ in children. Most liver injuries are caused by blunt trauma from motor vehicle crashes, falls, bicycle crashes, violence, or by a penetrating injury that tears or cuts the liver.

What is lacerated wound?

A laceration or cut refers to a skin wound. Unlike an abrasion, none of the skin is missing. A cut is typically thought of as a wound caused by a sharp object, like a shard of glass. Lacerations tend to be caused by blunt trauma.

What is the ICd 10 code for a lacerated liver?

Laceration of liver, unspecified degree, initial encounter 1 S36.113A is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. 2 The 2021 edition of ICD-10-CM S36.113A became effective on October 1, 2020. 3 This is the American ICD-10-CM version of S36.113A - other international versions of ICD-10 S36.113A may differ.

What is the secondary code for Chapter 20?

Use secondary code (s) from Chapter 20, External causes of morbidity, to indicate cause of injury. Codes within the T section that include the external cause do not require an additional external cause code. Type 1 Excludes.

How deep is a laceration?

If you are in a situation where the laceration is less than 10 centimeters long but more than 3 centimeters deep, you should query the provider on internal organ injuries if they were documented using the American Association for the Surgery of Trauma (AAST) grading scale.

How deep is a hepatic parenchyma?

Minor: Laceration involving capsule only or without significant involvement of hepatic parenchyma (less than one centimeter deep) Moderate: Laceration involving parenchyma but without major disruption of parenchyma (less than 10 centimeters long and less than three centimeters deep)

Can you code liver lacerations as minor?

Q: According to our software vendor, you can only code liver lacerations as minor, moderate, or major. According to all the educational materials I can find, however, liver lacerations are on a grading scale (grades 1-5). How does your institution code the liver laceration if they only give measurements of the lacerations?

Coding Guidelines

The appropriate 7th character is to be added to each code from block Injury of intra-abdominal organs (S36). Use the following options for the aplicable episode of care:

Specific Coding for Laceration of liver, unspecified degree

Non-specific codes like S36.113 require more digits to indicate the appropriate level of specificity. Consider using any of the following ICD-10 codes with a higher level of specificity when coding for laceration of liver, unspecified degree:

Index to Diseases and Injuries

The Index to Diseases and Injuries is an alphabetical listing of medical terms, with each term mapped to one or more ICD-10 code (s). The following references for the code S36.113 are found in the index:

Approximate Synonyms

The following clinical terms are approximate synonyms or lay terms that might be used to identify the correct diagnosis code:

Information for Patients

Your liver is the largest organ inside your body. It helps your body digest food, store energy, and remove poisons.

What is the code for laceration of liver?

S36.116A is a billable diagnosis code used to specify a medical diagnosis of major laceration of liver, initial encounter. The code S36.116A is valid during the fiscal year 2021 from October 01, 2020 through September 30, 2021 for the submission of HIPAA-covered transactions.

What are the symptoms of liver cancer?

Symptoms of liver disease can vary, but they often include swelling of the abdomen and legs, bruising easily, changes in the color of your stool and urine, and jaundice, or yellowing of the skin and eyes. Sometimes there are no symptoms.

What is the liver?

Your liver is the largest organ inside your body. It helps your body digest food, store energy, and remove poisons. There are many kinds of liver diseases: Diseases caused by viruses, such as hepatitis A, hepatitis B, and hepatitis C.

What are the symptoms of a hepatic injury?

When bleeding is present, patients will present symptoms of shock, with rapid heart rate, pale or bluish skin and cold teguments. Hepatic injury ranges from haematomas, which are described as collection of blood, of various sizes, shapes and locations, to large ruptures, lacerations of liver tissue of different depths.

What is the most common cause of death in hepatic trauma?

Surgery usually aims at controlling the hemorrhage as the most common cause of death in hepatic trauma in surgery is exsanguinations. Liver trauma, either blunt or penetrating consists of 5% of all trauma presentations with abdominal injury. It is prone to stab wounds and shooting wounds due to the abdominal position and the large surface covered.

What degree of injury is the least severe?

As observed, the degrees vary, starting with I, the least severe to VI, the most severe. The rule of thumb states that any injury classified at a stage higher than II will most likely require surgical correction and in some cases, preparation for blood transfusion.