Unspecified contusion of spleen, initial encounter

This code signifies a bruise to the spleen where the specific nature or severity of the contusion is not documented. It indicates an injury to the spleen without further detail regarding its grade or extent.

This code is appropriate for initial encounters when a splenic contusion is diagnosed, but the medical record lacks the specific information needed to assign a more precise code (e.g., grade of contusion). It is used when the physician documents "splenic contusion" without further elaboration.

• Only use this code when documentation does not specify the grade or type of splenic contusion.
• Always sequence this code as the primary diagnosis if it is the reason for the encounter.
• Ensure the "A" seventh character is used for the initial encounter for treatment of the injury.