Unsp injury of heart, unsp w or w/o hemopericardium, init

This code signifies an injury to the heart where the specific nature of the trauma (e.g., contusion, laceration, puncture) is not documented. It also indicates that it's unknown whether blood has collected in the pericardial sac surrounding the heart. This is an initial encounter for the injury.

Use this code when a patient presents with evidence of cardiac trauma, but diagnostic workup is incomplete, or the physician's documentation does not specify the exact type of heart injury. It is appropriate for the initial visit for this injury when further investigation or treatment is planned.

• Only use this code when the specific type of heart injury is truly unspecified in the medical record.
• Ensure the "initial encounter" seventh character is appropriate for the patient's first visit for this condition.
• Avoid using this code if more specific documentation, such as a cardiac contusion or laceration, is available.