2025 ICD-10-CM code S25.9
Injury of unspecified blood vessel of the thorax.
Yes, ICD-10-CM codes can be appended with a 7th character extension to indicate the encounter type (A = initial encounter, D = subsequent encounter, S = sequela).
Medical necessity for treatment related to an S25.9 diagnosis is established by the documented evidence of the injury, the associated symptoms and clinical findings, and the potential for complications if left untreated.
Clinicians diagnose this injury based on the patient's history of trauma, a physical examination including vascular assessment (checking for a thrill or bruit), laboratory studies (blood tests, BUN, and creatinine if imaging with contrast is planned), and imaging studies (X-rays, CT, MRI, color Doppler ultrasound). Treatment varies depending on the injury's severity and may include observation, supportive care, medication (anticoagulants, platelet therapy, blood pressure support), or surgery.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the thorax (S20-S29)
In simple words: An injury to a blood vessel in the chest area, but the exact blood vessel isn't specified. This could be a cut, tear, bruise, or other damage, and could be caused by things like a puncture wound, gunshot, squeezing force, or even during a medical procedure in the chest.
Injury of unspecified blood vessel of the thorax refers to a laceration, tear, contusion, or other damage to a blood vessel within the thoracic cavity.This injury can occur due to various traumatic events such as puncture wounds, gunshot wounds, external compression or force, or iatrogenic injury during thoracic procedures like catheterization or surgery. The specific blood vessel affected is not identified.
Example 1: A patient presents to the emergency department following a motor vehicle accident with chest pain and shortness of breath. Imaging reveals an injury to a blood vessel in the thorax, but the specific vessel is not identified. The patient is admitted for observation and supportive care., During a central venous catheter insertion, the patient experiences sudden chest pain and bleeding.The procedure is aborted, and imaging reveals injury to an unspecified thoracic blood vessel.The patient receives treatment to control the bleeding., A patient with a penetrating chest injury from a knife wound undergoes surgery.During the procedure, the surgeon discovers an injury to a thoracic blood vessel, but the exact vessel is difficult to isolate and identify due to the complex nature of the injury.
Documentation should include the details of the traumatic event, physical exam findings (including vascular assessment), results of laboratory and imaging studies, treatment provided, and the physician's clinical judgment regarding the unspecified nature of the injured vessel.
** It is important to document the diagnostic confidence (A, G, V, Z) as per outpatient care guidelines. While S25.9 indicates an unspecified thoracic vessel, it's crucial to document as much information as available regarding the possible location and type of vessel injured to guide treatment and ensure appropriate continuity of care.
- Specialties:Trauma surgery, thoracic surgery, cardiology, emergency medicine, critical care medicine
- Place of Service:Inpatient Hospital, Emergency Room - Hospital, Office, Outpatient Hospital