Laceration of gallbladder, initial encounter

This diagnosis code signifies a tear or cut in the wall of the gallbladder, the small organ that stores bile. Such an injury can result in the leakage of bile into the abdominal cavity, potentially leading to peritonitis or other serious complications.

This code is appropriate for documenting an initial presentation of a traumatic injury to the gallbladder, such as those sustained in motor vehicle accidents, falls, or direct abdominal trauma. It should be used when the patient is receiving active treatment for the laceration.

• Ensure documentation clearly specifies a laceration of the gallbladder, not just a contusion or other injury.
• Verify that this is the initial encounter for treatment of the injury; subsequent encounters will require different seventh characters.
• Always code external cause of injury codes in conjunction with this diagnosis to provide a complete picture of the event.