2025 ICD-10-CM code S38.3
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Injury - Injuries to the abdomen, lower back, lumbar spine, pelvis and external genitals Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Partial transection of the abdomen.
Modifiers may be applicable depending on the specific circumstances of the encounter and the services provided (e.g., surgical approach, anesthesia).Consult the current CPT modifier guidelines for applicable modifiers.
Medical necessity for treatment of a partial transection of the abdomen is established by the presence of the injury itself, supported by diagnostic imaging and clinical findings. The severity of the injury determines the need for various interventions, ranging from conservative management to complex surgical repair. Medical necessity is further supported by the potential for significant complications such as hemorrhage, infection, or organ dysfunction.
The clinical responsibility involves diagnosis and management of the injury. This includes taking a thorough patient history, performing a physical exam (including a vascular assessment), ordering appropriate laboratory and imaging studies, determining the need for surgical intervention, administering supportive care (e.g., pain medication, blood transfusions), and managing potential complications such as infection. Post-operative care and follow-up are also key elements of the clinical responsibility.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the abdomen, lower back, lumbar spine, pelvis and external genitals (S30-S39)
In simple words: Partial transection of the abdomen means a part of the abdomen is cut or torn. This can happen due to an accident, injury, or during surgery. It can cause pain, bleeding, and damage to internal organs. Doctors will assess the injury using tests and scans and treat it with medication, blood transfusions, or surgery.
Partial transection of the abdomen refers to a traumatic injury where part of the abdominal area is cut or severed. This can result from blunt or penetrating trauma (e.g., motor vehicle accidents, industrial accidents, sports injuries, puncture wounds, gunshot wounds), external compression or force, or iatrogenic injury during surgery.The injury may cause pain, bleeding (hematoma), shock, shortness of breath, tearing of the abdominal wall, damage to internal organs (stomach, liver, intestines), changes in distal pulse, hypotension, skin discoloration, and pseudoaneurysm formation. Diagnosis involves patient history, physical examination (including vascular assessment), laboratory studies (blood coagulation factors, platelets, BUN, creatinine), and imaging (X-rays, angiography, venography, duplex Doppler scans, MRI, CTA). Treatment options range from observation and supportive care (blood pressure support, transfusions, analgesics) to surgical repair, and antibiotic treatment for infection.
Example 1: A patient involved in a high-speed motor vehicle accident presents with severe abdominal pain and hypotension.Imaging reveals a partial transection of the mesenteric artery. The patient requires immediate surgical repair., During a laparoscopic cholecystectomy, the surgeon inadvertently causes a partial transection of the small bowel.The injury is immediately repaired during the procedure, and the patient recovers without complication., A patient sustains a stab wound to the abdomen during an assault.Examination reveals a partial transection of the liver and significant intra-abdominal bleeding. The patient undergoes emergency surgery for damage control and repair.
Detailed documentation should include the mechanism of injury, physical exam findings, results of all laboratory tests (including coagulation studies), and imaging reports. Operative reports should clearly detail the extent of the injury, repair techniques, and any complications.Post-operative progress notes should document the patient's recovery and any ongoing management.
** The seventh character (A, D, or S) should be added to indicate the encounter (initial, subsequent, or sequela).Accurate coding requires a complete understanding of the extent of the injury and any associated complications.
- Payment Status: Active
- Specialties:General Surgery, Trauma Surgery, Vascular Surgery
- Place of Service:Emergency Room - Hospital, Inpatient Hospital, Ambulatory Surgical Center