Moderate laceration of spleen, subsequent encounter

This code signifies a moderate-grade tear or cut in the spleen that is being addressed during a follow-up visit. This type of injury typically involves a capsular tear with parenchymal involvement, but without significant vascular disruption or active bleeding at the time of the subsequent encounter.

Use this code for patients presenting for ongoing management, monitoring, or evaluation of a previously diagnosed moderate splenic laceration. This includes visits for imaging follow-up, assessment of healing, or management of complications after the initial acute treatment phase.

• Ensure documentation clearly states "moderate" laceration and specifies a subsequent encounter.
• Do not use for the initial treatment of the injury; a different encounter character is required for the initial visit.
• Always review the full medical record to confirm the severity of the laceration and the encounter type.