Unspecified injury of gallbladder, initial encounter

This code signifies an injury to the gallbladder where the specific nature of the trauma (e.g., laceration, contusion, rupture) is not documented. It indicates that the patient is receiving initial treatment for this unspecified gallbladder injury.

Use this code when documentation confirms an injury to the gallbladder, but the physician has not specified the exact type of injury. This is appropriate for initial encounters where the diagnosis is still pending further investigation or when the specific injury type is unknown or unrecorded.

• Always seek clarification from the provider if the specific type of gallbladder injury is not documented, as more specific codes exist.
• This code should only be used for the initial encounter for treatment of the injury. Subsequent encounters will require a different seventh character.
• Ensure the documentation clearly states an "injury" to the gallbladder, not just a disease process.