Contusion of rectum, initial encounter

This code signifies a bruise or superficial injury to the rectum, typically resulting from blunt force trauma without a break in the skin or deeper tissue damage. It indicates an injury where the rectal tissue is compressed or crushed, leading to localized bleeding and swelling.

Use this code for initial encounters involving patients presenting with symptoms such as rectal pain, tenderness, or minor bleeding following a traumatic event. This includes injuries sustained from falls, direct blows to the perineum, or certain types of foreign body insertions that cause contusion but not laceration or perforation.

• Ensure documentation specifies "contusion" and not a more severe injury like a laceration or perforation.
• Verify this is the "initial encounter" for treatment of the contusion. Subsequent encounters will require a different seventh character.
• Always code any associated external cause of injury (e.g., fall, assault) in addition to this diagnosis.