ICD-10 Coding for Liver Laceration(S36.114, S36.115, S36.116, S36.113A)
Complete ICD-10-CM coding and documentation guide for Liver Laceration. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Liver Laceration
S36.1Primary Range
Injury of liver
This range includes codes specific to liver injuries, including lacerations of varying severity.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S36.114 | Minor laceration of liver | Use when imaging confirms a minor laceration with depth less than 1 cm. |
|
| S36.115 | Moderate laceration of liver | Use when imaging confirms a moderate laceration with specified depth and length. |
|
| S36.116 | Major laceration of liver | Use when imaging confirms a major laceration with specified disruption. |
|
| S36.113A | Unspecified laceration of liver | Use only when depth and length are not documented. |
|
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 minor liver laceration
Essential facts and insights about Liver Laceration
Primary ICD-10-CM Codes for liver laceration
Decision Criteria
clinical Criteria
- CT scan shows capsular tear or parenchymal depth <1 cm
Applicable To
- Capsular tear
- Parenchymal depth <1 cm
Excludes
- Major laceration of liver
- Moderate laceration of liver
Clinical Validation Requirements
- CT scan showing capsular tear or parenchymal depth <1 cm
Code-Specific Risks
- Misclassification if depth is not documented
Coding Notes
- Ensure depth is documented to avoid using unspecified codes.
S36.115 - Moderate laceration of liver
Use when imaging confirms a moderate laceration with specified depth and length.
Applicable To
- Parenchymal depth 1–3 cm
- Length <10 cm
Excludes
- Major laceration of liver
- Minor laceration of liver
Clinical Validation Requirements
- CT scan showing parenchymal depth 1–3 cm and length <10 cm
Coding Notes
Ensure both depth and length are documented to avoid misclassification.
S36.116 - Major laceration of liver
Use when imaging confirms a major laceration with specified disruption.
Applicable To
- Parenchymal disruption >10 cm long
- Parenchymal depth >3 cm
Excludes
- Minor laceration of liver
- Moderate laceration of liver
Clinical Validation Requirements
- CT scan showing parenchymal disruption >10 cm long or >3 cm deep
Coding Notes
Ensure depth and length are documented to avoid using unspecified codes.
S36.113A - Unspecified laceration of liver
Use only when depth and length are not documented.
Excludes
- Minor laceration of liver
- Moderate laceration of liver
- Major laceration of liver
Clinical Validation Requirements
- Lack of specific depth or length documentation
Coding Notes
Avoid using this code if specific measurements are available.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Open wound of abdomen, initial encounter
S31.8XXADifferential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Liver Laceration to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S36.114.
Impact
Clinical: Inaccurate assessment of injury severity., Regulatory: Increased risk of audit discrepancies., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Ensure imaging reports include measurements, Train staff on documentation standards
Impact
Reimbursement: Incorrect DRG assignment leading to reimbursement issues., Compliance: Potential for non-compliance with coding standards., Data Quality: Inaccurate data affecting clinical and administrative decisions.
Mitigation Strategy
Ensure precise documentation of depth and length from imaging studies.
Impact
Reimbursement: May result in lower reimbursement rates., Compliance: Increased risk of audit findings., Data Quality: Decreased accuracy in clinical data reporting.
Mitigation Strategy
Always document and code based on specific imaging findings.
Impact
Increased scrutiny on the use of unspecified codes when specific data is available.
Mitigation Strategy
Ensure all imaging and operative reports include specific measurements.
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 Liver Laceration, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Liver Laceration
Use these documentation templates to ensure complete and accurate documentation for Liver Laceration. These templates include all required elements for proper coding and billing.
Trauma Surgery
Specialty: SurgeryRequired Elements
- Mechanism of injury
- Imaging results
- Depth and length of laceration
- Associated injuries
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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