Major laceration of heart with hemopericardium, sequela

This code signifies a significant tear or wound to the heart muscle that has resulted in bleeding into the pericardial sac, the fluid-filled membrane surrounding the heart. The "sequela" designation indicates that this code is used for complications or conditions arising as a direct result of the initial injury, occurring after the acute phase has passed.

This code is appropriate for documenting long-term effects or complications stemming from a major laceration of the heart that was accompanied by hemopericardium. Examples include chronic pericardial effusions, constrictive pericarditis, or persistent cardiac dysfunction directly attributable to the original injury. It should be used when the patient is no longer in the initial treatment phase for the acute injury.

• Always ensure documentation clearly links the current condition as a direct consequence (sequela) of a previously treated major heart laceration with hemopericardium.
• Do not use this code for the initial acute injury; a separate acute injury code would be assigned for that phase.
• Consider additional codes for specific sequelae, such as chronic pericardial effusion (I31.2) or other cardiac complications, if documented.