Radiology Coding Alert

Question: A patient presented to an emergency department (ED) with complaints of abdominal pain. The radiologist performed an abdominal and pelvic CT scan without contrast. The findings list a 5 cm parenchymal laceration of the spleen.

What diagnosis codes do I need to assign?

Connecticut Subscriber

Answer: You’ll assign S36.032A (Major laceration of spleen, initial encounter) to report the splenic injury diagnosis.

To find the splenic laceration code, search for Laceration > spleen > major (massive) (stellate) S36.032- (Major laceration of spleen) in the ICD-10-CM Alphabetic Index. You’ll find a note beneath the descriptor for S36.032- defining a major laceration of the spleen as a cut “greater than 3 cm.” Additionally, the S36.032- requires a 7th character to complete the code. Since the patient presented the ED and was seeking active treatment for the injury, you’ll assign 7th character “A” to indicate the visit was an initial encounter.

The codes listed in the S36.03- (Laceration of spleen) subcategory are categorized by the size of the cut on the spleen. As mentioned above, S36.032- is reserved for a splenic laceration of more than 3 cm. Code S36.030- (Superficial (capsular) laceration of spleen) is designated for a laceration of less than 1 cm. You’ll assign S36.031- (Moderate laceration of spleen) for a laceration of the spleen measuring 1 to 3 cm.