Question

the patient was the driver in a non-traffic motor vehicle accident. the patient is now bleeding into 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 it's entirety what are the cpt code and the icd-10-cm code​

Answer 1

The answer is: ICD-10-CM: hospitalized and outpatient cases. CPT: coding of outpatient procedures.

Step-by-step explanation:

Diagnostic classification system and procedures:

ICD-10-CM: Coding of diagnoses for hospitalized and outpatient cases.

ICD-10-PCS: Coding procedures for hospitalized cases.

ICD-10 does not affect the coding of outpatient procedures. They continue to use the CPT code system.

The answer is: ICD-10-CM: hospitalized and outpatient cases. CPT: coding of outpatient procedures.

Answer 2

The ICD-10 CM diagnosis code:

• For injured person, unspecified motor vehicle accident, nontraffic: V89.0
• Laceration of spleen: S36.03

The CPT procedural code for complete removal of spleen: 38100

Step-by-step explanation:

The ICD-10 code V89.0 is used to describe the circumstance which led to the injury. It does not describe the nature of the injury and hence requires much more detailing while coding for reimbursement purposes.

The ICD-10 code S36.03 denotes laceration of spleen; S36.030 for superficial laceration; S36.031 for moderate laceration; and S36.032 for major laceration.

The CPT procedural code for complete excision of spleen or complete or total splenectomy is 38100. Any abdominal injury or laceration might cause hemorrhage or bleeding in the spleen. In order to control further bleeding, the spleen is either removed in complete or partial.