The patient was the driver in a non-traffic motor vehicle accident. The patient is now bleeding into the abdominal cavity due to trauma and hemorrhage of the spleen. The physician brings this patient to the operating room to remove the spleen in order to control this patient’s bleeding. The major vessels of the lacerated spleen were carefully dissected, and the spleen was removed in its entirety.

The ICD-10 diagnosis code : An injured person, unspecified motor vehicle accident, nontraffic: V89.0 and for Laceration of spleen: S36.03

The CPT procedural code for removal of spleen in its entirety: 38100

Explanation:

The ICD-10 code V89.0 details the circumstance that caused the injury.

The ICD-10 code S36.03 refers laceration of spleen. The code specifies in the following way:

S36.030 for superficial laceration; S36.031 for moderate laceration; and S36.032 for major laceration.

Any abdominal injury or laceration might cause hemorrhage or bleeding in the abdominal organs like spleen. In order to control further bleeding, the spleen is either removed in its entirety or partially.  

The CPT procedural code for complete excision of spleen or total splenectomy is 38100.

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