Laceration of uterus, initial encounter

This diagnosis code signifies a tear or cut in the uterine wall, which can range from superficial to deep. Such an injury often results from trauma, surgical procedures, or complications during childbirth. It indicates the initial presentation and treatment of this specific uterine injury.

Apply this code when documenting the first instance of a uterine laceration, such as those occurring during a complicated vaginal delivery, following a uterine perforation during a gynecological procedure (e.g., D&C, hysteroscopy), or due to external abdominal trauma. This code is appropriate for the initial hospital stay or outpatient visit where the laceration is identified and managed.

• Ensure documentation clearly specifies "laceration" of the uterus, not just a contusion or hematoma.
• Verify that this is indeed the initial encounter for this specific injury. Subsequent care would use a different encounter character.
• Always code any associated external cause of injury (e.g., Y76.0 for perforation during surgery) and place of occurrence codes.