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2025 ICD-10-CM code S55.919A

Laceration of unspecified blood vessel at the forearm level of an unspecified arm. This code is used for the initial encounter.

Use secondary codes from Chapter 20 (External causes of morbidity) to indicate the cause of injury.An additional code should be used to identify any retained foreign body (Z18.-), if applicable.

Medical necessity for the evaluation and treatment of a lacerated blood vessel is established by the presence of the injury and associated symptoms. The extent of the injury and the potential for complications will dictate the appropriate level of care, such as observation, wound closure, or vascular repair.

The physician is responsible for diagnosing the laceration based on physical examination, including assessment of sensation, reflexes, and vascular status. Imaging studies like X-rays, ultrasound, venography, angiography, arteriography, duplex Doppler scan, MRA, and CTA may be necessary. Treatment involves controlling bleeding, observation, and possible surgical repair of the blood vessel, which may include endovascular techniques.

In simple words: This code describes a deep cut or tear to a blood vessel in your forearm. The doctor hasn't yet determined which specific blood vessel is injured or whether it's in your right or left arm.

Laceration of unspecified blood vessel at the forearm level of an unspecified arm refers to an irregular deep cut or tear to the blood vessels that supply the region of the forearm.The injury can be caused by various traumas, such as a knife or shards of broken glass, motor vehicle accidents, punctures, gunshot wounds, or during surgery.At the initial encounter, the provider has not specified which blood vessel is injured nor the laterality (right or left arm).

Example 1: A patient presents to the emergency room after falling through a glass window, resulting in a deep laceration to their right forearm with significant bleeding.The physician notes the injury appears to involve a blood vessel but further imaging is required to determine the extent of the vascular damage.S55.919A is used for the initial encounter., During a surgical procedure on the left forearm, a small blood vessel is inadvertently lacerated. The surgeon immediately repairs the vessel.S55.919A is used to code the injury, even though it occurred during a surgical procedure, as it describes the injury itself., A patient arrives at the clinic with a deep cut on their forearm after being attacked by a dog. The wound is actively bleeding.The physician notes concern for vascular involvement.The physician documents the laceration to the forearm with the code S55.919A as the specific blood vessel injured is not yet determined at this initial encounter.

Documentation should include the cause and location of the injury, the presence and extent of bleeding, any associated symptoms (e.g., pain, numbness, tingling), and results of diagnostic imaging or vascular studies.Details of treatment provided, such as wound closure or vascular repair, should also be documented.

** Excludes1: birth trauma (P10-P15), obstetric trauma (O70-O71). Excludes2: burns and corrosions (T20-T32), frostbite (T33-T34), injuries of wrist and hand (S60-S69), insect bite or sting, venomous (T63.4).

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