ICD-10 Code D78.11 | Accidental pnctr & lac of the spleen dur proc on the spleen Symptoms, Diagnosis, Billing

Accidental puncture and laceration of the spleen during a procedure on the spleen can occur due to surgical mishaps or trauma. This condition is clinically significant as it may lead to splenic hemorrhage, infection, or other complications requiring immediate medical intervention. The ICD-10 Code D78.11 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and track such incidents.

What is ICD-10 Code D78.11 for Accidental pnctr & lac of the spleen dur proc on the spleen?

ICD-10 Code D78.11 represents accidental puncture and laceration of the spleen during a procedure on the spleen. This code is applicable when a patient experiences splenic injury as a complication of surgical intervention. It is essential for clinical documentation and billing to accurately reflect the nature of the injury and its implications for patient care.

ICD-10 Code D78.11 – Clinical Definition and Explanation of Accidental pnctr & lac of the spleen dur proc on the spleen

Accidental puncture and laceration of the spleen during a procedure can result from surgical errors or unexpected complications. This condition necessitates prompt medical attention to prevent severe outcomes such as hemorrhage or infection. Understanding this diagnosis is crucial for appropriate management and treatment.

Key Clinical Features:

• Sudden onset of abdominal pain, particularly in the left upper quadrant.
• Signs of internal bleeding, such as hypotension or tachycardia.
• Possible splenomegaly or palpable mass in the abdomen.
• History of recent surgical procedures involving the spleen.

ICD-10 Code D78.11 for Accidental pnctr & lac of the spleen dur proc on the spleen – SOAP Notes & Clinical Use

ICD-10 Code D78.11 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans related to accidental splenic injury. This code is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition.

What Does ICD-10 Code D78.11 for Accidental pnctr & lac of the spleen dur proc on the spleen Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D78.11 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of splenic injury. This code is vital for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code D78.11 – Accidental pnctr & lac of the spleen dur proc on the spleen

Accidental puncture and laceration of the spleen requires immediate medical evaluation and intervention to prevent complications. Treatment may vary based on the severity of the injury.

Antibiotic Therapy:

• First-line: Ceftriaxone 1-2 g IV every 24 hours.
• Alternative: Piperacillin-tazobactam 3.375 g IV every 6-8 hours.
• Duration: Typically 7-14 days, depending on clinical response.

Supportive Care:

• Monitor vital signs closely for signs of shock.
• Provide intravenous fluids to maintain hemodynamic stability.
• Consider blood transfusions if significant hemorrhage occurs.

Infection Control:

• Implement standard precautions to prevent infection.
• Isolate patients with suspected splenic abscesses.
• Educate staff on proper handling of splenic injuries.

How to Document Symptoms of Accidental pnctr & lac of the spleen dur proc on the spleen (ICD-10 D78.11) in SOAP Notes

Subjective:

• Patient reports sudden left upper quadrant pain post-surgery.
• Complains of dizziness and lightheadedness.
• History of recent splenic procedure.
• Denies fever or chills.

Objective:

• Vital signs: BP 90/60 mmHg, HR 110 bpm.
• Abdominal exam reveals tenderness in the left upper quadrant.
• Possible splenomegaly noted on palpation.
• CT scan shows splenic laceration.

Secure, compliant, and built for trust

HIPAA-compliant and designed with privacy in mind, your patient’s data is protected. Focus on care while we safeguard your information.

Learn more

SOAP Note Guidelines for Diagnosing Accidental pnctr & lac of the spleen dur proc on the spleen (ICD-10 Code D78.11)

Assessment:

• Accidental puncture and laceration of the spleen, moderate severity.
• ICD-10 Code: D78.11.
• Recent surgical intervention as a contributing factor.

Plan:

• Initiate IV fluids and monitor hemodynamics.
• Administer antibiotics as per protocol.
• Consult surgery for potential splenectomy.
• Schedule follow-up imaging to assess splenic status.

Treatment & Plan Section for ICD-10 Code D78.11 – Accidental pnctr & lac of the spleen dur proc on the spleen

• First-line pharmacologic treatment includes IV antibiotics.
• Non-pharmacologic strategies involve close monitoring and supportive care.
• Regular monitoring of vital signs and hemoglobin levels.
• Follow-up imaging to evaluate splenic healing or complications.

Using ICD-10 Code D78.11 for Accidental pnctr & lac of the spleen dur proc on the spleen in Billing & SOAP Note Compliance

• Select accurate subcodes based on clinical severity or complications.
• Document symptoms clearly under Subjective (S) and Objective (O) in SOAP notes.
• Ensure treatment plans align with clinical guidelines to support justified billing.
• Only list CPT codes that are commonly billed with ICD-10 Code D78.11 based on standard medical coding practices.

Related ICD-10 Codes Often Used with Accidental pnctr & lac of the spleen dur proc on the spleen

• D73.0 – Splenic cyst
• D73.1 – Splenic abscess
• D75.9 – Other specified disorders of spleen

ICD-10 Code D78.11 in Medical Billing and Insurance for Accidental pnctr & lac of the spleen dur proc on the spleen

ICD-10 Code D78.11 is critical for accurate billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Ensure documentation includes details of the procedure leading to injury.
• Use the code in conjunction with relevant CPT codes for surgical interventions.
• Highlight any complications in the medical record to support claims.

Common CPT Pairings: