2025 ICD-10-CM code D78
(Active) Effective Date: N/A Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism - Intraoperative and postprocedural complications of the spleen Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89) Feed
Intraoperative and postprocedural complications of the spleen.
Medical necessity is established by documenting the specific complication and its relationship to the surgical procedure.The need for any interventions performed to address the complication should also be justified.
The spleen is a highly vascular organ located in the upper left abdomen that plays a role in blood cell production and removal.Intraoperative complications can lead to excessive bleeding, infection, and blood clots. Postprocedural complications may present with pain and swelling at the injury site. Diagnosis is based on patient history, physical examination, observation, signs, and symptoms. Intraoperative diagnosis relies heavily on direct observation during the procedure. Postprocedural diagnosis might require imaging studies like ultrasound or X-rays. Lab tests such as CBC (including hemoglobin and hematocrit), coagulation tests (PT, aPTT, TT), and platelet count may be necessary. Treatment typically involves surgical repair, potential blood transfusion for significant blood loss, and supportive care.
- Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89)
- D78-D78.89
In simple words: This code refers to problems with the spleen that happen during or right after surgery. These problems can include bleeding, bruising (hematoma), punctures, or tears in the spleen.These issues may or may not be related to a pre-existing spleen condition.
This code encompasses complications such as hemorrhage, hematoma, puncture, and laceration of the spleen that occur during a surgical procedure (intraoperative) or immediately following it (postprocedural). These complications may or may not be directly related to any existing splenic disease.
Example 1: A patient undergoing a splenectomy (surgical removal of the spleen) experiences excessive bleeding during the procedure due to a tear in the splenic artery. This would be coded as D78., During a colonoscopy, the spleen is accidentally punctured.This is considered an intraoperative complication and would be coded as D78., Following a splenorrhaphy (surgical repair of the spleen), the patient develops a hematoma at the surgical site, requiring further intervention. This postprocedural complication would be coded as D78.
Documentation should clearly specify the nature of the complication (e.g., hemorrhage, hematoma, puncture, laceration), when it occurred (intraoperative or postprocedural), and the specific procedure during which it arose. Any associated symptoms, diagnostic tests (e.g., imaging, lab results), and treatment provided should also be documented.
- Specialties:General surgery, Trauma surgery, Surgical oncology
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center