Mild laceration of heart with hemopericardium, sequela

This code signifies a past injury to the heart muscle, specifically a mild tear, that was accompanied by bleeding into the pericardial sac (the sac surrounding the heart). The "sequela" indicates that this code is used to report a current condition or complication that is a direct result of that original heart laceration and hemopericardium, even if the initial injury has healed.

Use this code when documenting a patient presenting with long-term effects or complications directly attributable to a previously sustained mild cardiac laceration with hemopericardium. This could include conditions like chronic pericardial effusion, constrictive pericarditis, or other cardiac issues that developed as a consequence of the initial trauma. It is not for reporting the initial acute injury.

• Always ensure documentation clearly links the current condition to the past cardiac laceration and hemopericardium.
• This code requires a seventh character of 'S' for sequela, indicating a late effect.
• Do not use this code for the initial encounter or subsequent acute care of the original injury.