Laceration of heart without hemopericardium, init encntr

This code signifies a traumatic injury to the heart muscle where the tissue is torn or cut, but there is no associated bleeding into the pericardial sac (the membrane surrounding the heart). This type of injury can result from blunt or penetrating trauma to the chest.

Apply this code for patients presenting with a documented laceration of the heart, confirmed by imaging or surgical exploration, where hemopericardium has been explicitly ruled out. This code is appropriate for the initial treatment phase of such an injury.

• Ensure documentation clearly states "without hemopericardium" to support this specific code.
• Verify the encounter is the initial treatment for the injury; subsequent encounters will require a different seventh character.
• Always code the external cause of the injury in addition to this diagnosis code.