Q&A: Liver lacerations

Q: According to our software vendor, you can only code liver lacerations as minor, moderate, or major. According to all the educational materials I can find, however, 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? 

A: To start, the ICD-10-CM Tabular List gives the measurements for each of the three definitions. They are as follow:

• Minor: Laceration involving capsule only or without significant involvement of hepatic parenchyma (less than one centimeter deep)
• Moderate: Laceration involving parenchyma but without major disruption of parenchyma (less than 10 centimeters long and less than three centimeters deep)
• Major: Laceration with significant disruption of hepatic parenchyma (greater than 10 centimeters long and three centimeters deep) or moderate multiple lacerations with or without hematoma

Also, check to see if there is a nosology note in your encoder. Coders should be instructed to follow these guides and should query if the documentation doesn’t provide a laceration depth or length.

If you are in a situation where the laceration is less than 10 centimeters long but more than 3 centimeters deep, you should query the provider on internal organ injuries if they were documented using the American Association for the Surgery of Trauma (AAST) grading scale. Specifically, query for internal organ lacerations and hematomas.

Editor’s note: This question and answer were adapted from a thread on the ACDIS Forum. To learn more about participating on the Forum, click here.