ICD-10 Coding for Splenic Lesion(S36.031A, C26.1, D18.09)
Complete ICD-10-CM coding and documentation guide for Splenic Lesion. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Splenic Lesion
S36.0-S36.9Primary Range
Injury of spleen
This range includes codes for traumatic injuries to the spleen, such as lacerations and ruptures.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S36.031A | Moderate laceration of spleen, initial encounter | Use for moderate lacerations of the spleen with documented depth of 1-3 cm. |
|
| C26.1 | Malignant neoplasm of spleen | Use for confirmed primary malignant tumors of the spleen. |
|
| D18.09 | Hemangioma of spleen | Use for benign vascular lesions of the spleen confirmed by imaging or biopsy. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for splenic lesion
Essential facts and insights about Splenic Lesion
Primary ICD-10-CM Codes for splenic lesion
Decision Criteria
clinical Criteria
- CT scan confirms moderate laceration with no active bleeding.
Applicable To
- Moderate splenic laceration
Clinical Validation Requirements
- CT scan showing 1-3 cm parenchymal laceration
- No active contrast extravasation
Code-Specific Risks
- Misclassification as minor or major laceration
Coding Notes
- Ensure documentation specifies the depth and extent of the laceration.
C26.1 - Malignant neoplasm of spleen
Use for confirmed primary malignant tumors of the spleen.
Applicable To
- Primary splenic cancer
Excludes
- Secondary malignant neoplasm of spleen (C78.89)
Clinical Validation Requirements
- Biopsy confirming malignancy
- Imaging showing heterogeneous mass with necrosis
Coding Notes
Ensure histological confirmation of malignancy is documented.
D18.09 - Hemangioma of spleen
Use for benign vascular lesions of the spleen confirmed by imaging or biopsy.
Applicable To
- Benign vascular tumor of spleen
Excludes
- Malignant vascular tumors of spleen (C26.1)
Clinical Validation Requirements
- Imaging showing peripheral nodular enhancement
- Biopsy confirming benign nature
Coding Notes
Document imaging findings clearly to differentiate from malignant lesions.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Open wound of abdomen, initial encounter
S31.83XAPersonal history of malignant neoplasm of lymphoid, hematopoietic and related tissue
Z85.06Splenomegaly, not elsewhere classified
R16.1Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Splenic Lesion to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S36.031A.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Non-compliance with coding standards., Financial: Potential for denied claims or reduced reimbursement.
Mitigation Strategy
Use structured templates for documentation., Ensure imaging reports are detailed and specific.
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Could result in non-compliance with coding guidelines., Data Quality: Reduces the accuracy of clinical data.
Mitigation Strategy
Ensure documentation specifies the exact nature and extent of the lesion.
Impact
High risk of audit if unspecified codes are used when specific details are available.
Mitigation Strategy
Ensure all documentation includes specific details of the splenic lesion.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Splenic Lesion, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Splenic Lesion
Use these documentation templates to ensure complete and accurate documentation for Splenic Lesion. These templates include all required elements for proper coding and billing.
Traumatic splenic injury
Specialty: Trauma SurgeryRequired Elements
- Injury mechanism
- CT findings
- Laceration depth
- Associated injuries
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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