Laceration of heart without hemopericardium, sequela

This code signifies a past injury to the heart muscle characterized by a tear or wound, but specifically without the complication of blood accumulating in the sac surrounding the heart (hemopericardium) at the time of the initial injury. The "sequela" designation indicates that this code is used to report a condition or complication that arises as a direct result of that original heart laceration, long after the acute phase of the injury has passed.

Use this code when documenting a current clinical condition or symptom that is a direct consequence of a previously sustained laceration of the heart, where the initial injury did not involve hemopericardium. This applies to follow-up encounters for chronic issues stemming from the cardiac trauma, such as scar tissue formation, persistent arrhythmias, or other long-term cardiac dysfunction directly attributable to the old laceration.

• Always use an additional code to specify the nature of the sequela (e.g., I42.8 for other cardiomyopathies, I47.1 for supraventricular tachycardia).
• Ensure documentation clearly links the current condition to the historical heart laceration.
• The "S" in the 7th character indicates sequela; do not use for initial or subsequent encounters for the acute injury.