Superficial (capsular) laceration of spleen, sequela

This code signifies a superficial tear or cut in the outer layer (capsule) of the spleen, representing a long-term complication or late effect of an initial injury. It indicates that the patient is currently experiencing issues directly attributable to a previously sustained, non-penetrating splenic laceration.

Apply this code when documentation clearly links current symptoms or conditions to a past, superficial splenic capsular injury. This is appropriate for follow-up encounters where the patient is being treated for sequelae such as chronic pain, adhesions, or other persistent issues arising from the original trauma.

• Ensure documentation explicitly states "sequela" or "late effect" and clearly links the current condition to a past superficial splenic laceration.
• This code requires a seventh character "S" for sequela, indicating that the initial injury has healed but is causing ongoing problems.
• Do not use for initial injury encounters or for active treatment of the acute laceration.