Moderate laceration of heart with hemopericardium, sequela

This diagnosis code signifies a heart injury characterized by a tear of moderate severity in the cardiac muscle, accompanied by the presence of blood within the pericardial sac. This condition is a serious form of cardiac trauma that can impair heart function and lead to life-threatening complications.

Apply this code when documenting the long-term effects or complications arising from a previously sustained moderate laceration of the heart that resulted in hemopericardium. This is appropriate for follow-up encounters where the sequelae of the initial injury are being addressed, such as chronic pericardial effusion, adhesions, or persistent cardiac dysfunction directly attributable to the original trauma.

• Ensure documentation clearly links the current condition to the previous moderate heart laceration with hemopericardium.
• This "S" seventh character indicates a sequela, meaning it's used for complications or conditions that arise as a direct result of the initial injury after the acute phase has passed.
• Do not use this code for the initial acute injury; a different seventh character would be appropriate for the initial encounter.