Major contusion of spleen, subsequent encounter

This code signifies a significant bruise or bleeding within the spleen, occurring after the initial treatment of the injury. It indicates that the patient is receiving follow-up care for a splenic contusion that was previously diagnosed and managed.

Apply this code when documenting care for a patient who is returning for evaluation, treatment, or monitoring of a major splenic contusion. This includes scenarios like follow-up imaging to assess healing, medication adjustments, or observation for potential complications after the initial injury.

• Ensure documentation clearly states "subsequent encounter" or similar language indicating follow-up care.
• Confirm the contusion is explicitly described as "major" in the clinical notes.
• Do not use for the initial treatment of the injury; a different code would apply for the acute phase.