Unspecified injury of uterus, initial encounter

This code signifies an injury to the uterus where the specific nature or type of trauma is not documented. It indicates that the uterus has sustained some form of damage, but further details regarding the injury (e.g., laceration, contusion, rupture) are unknown at the time of the initial assessment.

This code is appropriate for the initial encounter when a patient presents with signs or symptoms of uterine injury, but diagnostic workup is incomplete, or the provider has not yet specified the exact type of injury. It may be used in emergency department settings or during initial consultations following trauma.

• Only use this code when the specific type of uterine injury is truly unspecified in the medical record.
• Always strive for a more specific code if documentation allows, as this is a "not otherwise specified" (NOS) code.
• Ensure the "A" for initial encounter is appropriate; subsequent encounters would use "D" or "S" as the 7th character.