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ICD-10 Coding for Abdominal Hematoma(S30.1, T81.0, D68.3)

Complete ICD-10-CM coding and documentation guide for Abdominal Hematoma. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Hematoma of the AbdomenAbdominal Wall Hematoma

Related ICD-10 Code Ranges

Complete code families applicable to Abdominal Hematoma

S30-S39Primary Range

Injuries to the abdomen, lower back, lumbar spine, pelvis and external genitals

This range includes codes for traumatic injuries to the abdominal area, including hematomas.

Complications of procedures, not elsewhere classified

This range includes codes for postprocedural complications such as hematomas.

Other disorders of peritoneum

This range includes codes for hemoperitoneum, which may be confused with localized hematomas.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
S30.1Contusion of abdominal wallUse for traumatic hematomas of the abdominal wall confirmed by imaging.
  • CT or MRI showing hematoma confined to abdominal wall layers
  • History of trauma
T81.0Hemorrhage and hematoma complicating a procedure, not elsewhere classifiedUse for hematomas developing as a complication of a procedure.
  • Operative report confirming hematoma at surgical site
  • Temporal relationship to procedure
D68.3Hemorrhagic disorder due to extrinsic circulating anticoagulantsUse when a hematoma is related to anticoagulant therapy.
  • Documentation of anticoagulant use
  • INR or other coagulation test results

Clinical Decision Support

Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.

Key Information: ICD-10 code for abdominal hematoma

Essential facts and insights about Abdominal Hematoma

The ICD-10 code for a traumatic abdominal hematoma is S30.1, while postprocedural hematomas are coded as T81.0.

Primary ICD-10-CM Codes for hematoma abdomen

Contusion of abdominal wall
Non-billable Code

Decision Criteria

clinical Criteria

  • Presence of a palpable mass and ecchymosis with a history of trauma

Applicable To

  • Traumatic hematoma of abdominal wall

Excludes

  • Injury of internal organs

Clinical Validation Requirements

  • CT or MRI showing hematoma confined to abdominal wall layers
  • History of trauma

Code-Specific Risks

  • Misclassification as unspecified abdominal injury

Coding Notes

  • Ensure documentation specifies the traumatic nature and location of the hematoma.

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Place of occurrence of the external cause

Y92.-
Use to specify the location of the injury event.

Surgical procedure as the cause of abnormal reaction

Y83.2
Use to specify the procedure causing the hematoma.

Long-term (current) use of anticoagulants

Z79.01
Document ongoing anticoagulant therapy.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Hemoperitoneum

K66.1
Use K66.1 for intraperitoneal bleeding, confirmed by paracentesis or imaging.

Contusion of abdominal wall

S30.1
Use S30.1 for traumatic hematomas not related to procedures.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Abdominal Hematoma to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S30.1.

Impact

Clinical: Mismanagement of anticoagulation therapy., Regulatory: Non-compliance with coding standards., Financial: Potential denial of claims.

Mitigation Strategy

Review medication history, Document INR levels

Impact

Reimbursement: May lead to lower reimbursement rates., Compliance: Increases risk of audit failures., Data Quality: Reduces accuracy of clinical data.

Mitigation Strategy

Use specific codes like S30.1 or T81.0 based on the context.

Impact

Use of unspecified codes for abdominal hematomas.

Mitigation Strategy

Educate staff on specific code selection.

Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.

Frequently Asked Questions

Common questions about ICD-10 coding for Abdominal Hematoma, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Abdominal Hematoma

Use these documentation templates to ensure complete and accurate documentation for Abdominal Hematoma. These templates include all required elements for proper coding and billing.

Post-surgical hematoma

Specialty: Surgery

Required Elements

  • Procedure details
  • Hematoma size and location
  • Imaging findings

Example Documentation

Patient developed a 5cm hematoma at the incision site 2 days post-laparoscopic appendectomy.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Post-op hematoma noted.
Good Documentation Example
5cm hematoma at incision site, 2 days post-laparoscopic appendectomy, confirmed by ultrasound.
Explanation
The good example provides specific size, location, and confirmation method.

Need help with ICD-10 coding for Abdominal Hematoma? Ask your questions below.

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