Major laceration of liver, initial encounter

This code signifies a severe, deep tear of the liver parenchyma, often extending through the capsule and into the deeper tissues. Such injuries typically result in significant hemorrhage and potential compromise of liver function. It represents the initial presentation and treatment of this specific type of liver trauma.

Apply this code for patients presenting with blunt or penetrating abdominal trauma confirmed to have a major laceration of the liver, as documented by imaging (e.g., CT scan) or surgical exploration. This is appropriate for the initial hospital admission or encounter where the injury is first diagnosed and managed.

• Ensure documentation clearly specifies "major laceration" or a similar high-grade injury (e.g., AAST Grade IV-V) to support this code.
• Verify that the encounter is the "initial encounter" for this specific injury. Subsequent care would use the appropriate S36.116D or S36.116S.
• Code all associated injuries and external cause codes (e.g., Y99.8) to provide a complete clinical picture.