Liver lacerations

chwcdi

I am curious to hear any feedback on how liver lacerations are captured by other facilities. According to 3M you can only code as minor, moderate, or major. However, according to all educational materials, liver lacerations are on a grading scale (grades 1-5). How does your institution code the liver laceration if they only give measurements of the lacerations? 

ekilbo@ghs.org

The ICD-10-CM Tabular lists measurements for each of the three definitions.  There is also a 3M Nosology note in the encoder.  Coders are instructed to follow these guides and should query if the documentation doesn't provide a laceration depth/length.

Minor - Laceration involving capsule only or without significant involvement of hepatic parenchyma (ie: less than 1cm deep)

Moderate - Laceration involving parenchyma but without major disruption of parenchyma (ie: less that 10cm long and less than 3cm deep)

Major - Laceration with significant disruption of hepatic parenchyma (ie: greater than 10cm long and 3m deep) or moderate multiple lacerations with or without hematoma

Erik Kilbo, CCDS, CDIP, CCS, CPC-I
Manager - Enterprise HIM Coding
Greenville Health System

chwcdi

Thank you ekilbo@ghs.org, thank you for your response. So what if you are in a situation where the laceration is less than 10 cm long but more than 3 cm deep? Do the coders take more by length or depth? 

lprescott1

I would query the provider for clarification

jackietouch@aol.com

We query the provider on internal organ injuries if documented using AAST grading scale (lacerations and hematomas).

msk02williams@aol.com

Hi! Does anyone take the measurements and grades (if noted)  from the Radiology reports or do you query the provider for them to add to their note?