2024 ICD-10-CM Diagnosis Code S36.030D

Superficial (capsular) laceration of spleen, subsequent encounter

ICD-10-CM Code:
S36.030D
ICD-10 Code for:
Superficial (capsular) laceration of spleen, subs encntr
Is Billable?
Yes - Valid for Submission
Chronic Condition Indicator: [1]
Not chronic
Code Navigator:

Code Classification

  • Injury, poisoning and certain other consequences of external causes
    (S00–T88)
    • Injuries to the abdomen, lower back, lumbar spine, pelvis and external genitals
      (S30-S39)
      • Injury of intra-abdominal organs
        (S36)

S36.030D is a billable diagnosis code used to specify a medical diagnosis of superficial (capsular) laceration of spleen, subsequent encounter. The code is valid during the current fiscal year for the submission of HIPAA-covered transactions from October 01, 2023 through September 30, 2024. The code is exempt from present on admission (POA) reporting for inpatient admissions to general acute care hospitals.

S36.030D is a subsequent encounter code, includes a 7th character and should be used after the patient has completed active treatment for a condition like superficial (capsular) laceration of spleen. According to ICD-10-CM Guidelines a "subsequent encounter" occurs when the patient is receiving routine care for the condition during the healing or recovery phase of treatment. Subsequent diagnosis codes are appropriate during the recovery phase, no matter how many times the patient has seen the provider for this condition. If the provider needs to adjust the patient's care plan due to a setback or other complication, the encounter becomes active again.

Approximate Synonyms

The following clinical terms are approximate synonyms or lay terms that might be used to identify the correct diagnosis code:

  • Capsular tear of spleen
  • Capsular tear of spleen
  • Capsular tear without major disruption of parenchyma of spleen AND with open wound in abdominal cavity
  • Injury of spleen with open wound into abdominal cavity
  • Laceration of spleen
  • Laceration of spleen
  • Laceration of spleen
  • Minor laceration of spleen
  • Open injury of spleen
  • Open injury of spleen
  • Open injury of spleen

Clinical Classification

Coding Guidelines

The appropriate 7th character is to be added to each code from block Injury of intra-abdominal organs (S36). Use the following options for the aplicable episode of care:

  • A - initial encounter
  • D - subsequent encounter
  • S - sequela

Present on Admission (POA)

S36.030D is exempt from POA reporting - The Present on Admission (POA) indicator is used for diagnosis codes included in claims involving inpatient admissions to general acute care hospitals. POA indicators must be reported to CMS on each claim to facilitate the grouping of diagnoses codes into the proper Diagnostic Related Groups (DRG). CMS publishes a listing of specific diagnosis codes that are exempt from the POA reporting requirement. Review other POA exempt codes here.

CMS POA Indicator Options and Definitions

POA IndicatorReason for CodeCMS will pay the CC/MCC DRG?
YDiagnosis was present at time of inpatient admission.YES
NDiagnosis was not present at time of inpatient admission.NO
UDocumentation insufficient to determine if the condition was present at the time of inpatient admission.NO
WClinically undetermined - unable to clinically determine whether the condition was present at the time of inpatient admission.YES
1Unreported/Not used - Exempt from POA reporting. NO

Convert S36.030D to ICD-9-CM

  • ICD-9-CM Code: V58.89 - Other specfied aftercare
    Approximate Flag - The approximate mapping means there is not an exact match between the ICD-10 and ICD-9 codes and the mapped code is not a precise representation of the original code.

Patient Education


Spleen Diseases

Your spleen is an organ above your stomach and under your ribs on your left side. It is about as big as your fist. The spleen is part of your lymphatic system, which fights infection and keeps your body fluids in balance. It contains white blood cells that fight germs. Your spleen also helps control the amount of blood in your body, and destroys old and damaged cells.

Certain diseases might cause your spleen to swell. You can also damage or rupture your spleen in an injury, especially if it is already swollen. If your spleen is too damaged, you might need surgery to remove it. You can live without a spleen. Other organs, such as your liver, will take over some of the spleen's work. Without a spleen, however, your body will lose some of its ability to fight infections.


[Learn More in MedlinePlus]

Wounds and Injuries

An injury is damage to your body. It is a general term that refers to harm caused by accidents, falls, hits, weapons, and more. In the U.S., millions of people injure themselves every year. These injuries range from minor to life-threatening. Injuries can happen at work or play, indoors or outdoors, driving a car, or walking across the street.

Wounds are injuries that break the skin or other body tissues. They include cuts, scrapes, scratches, and punctured skin. They often happen because of an accident, but surgery, sutures, and stitches also cause wounds. Minor wounds usually aren't serious, but it is important to clean them. Serious and infected wounds may require first aid followed by a visit to your doctor. You should also seek attention if the wound is deep, you cannot close it yourself, you cannot stop the bleeding or get the dirt out, or it does not heal.

Other common types of injuries include:

  • Animal bites
  • Bruises
  • Burns
  • Dislocations
  • Electrical injuries
  • Fractures (broken bones)
  • Sprains and strains

[Learn More in MedlinePlus]

Code History

  • FY 2024 - No Change, effective from 10/1/2023 through 9/30/2024
  • FY 2023 - No Change, effective from 10/1/2022 through 9/30/2023
  • FY 2022 - No Change, effective from 10/1/2021 through 9/30/2022
  • FY 2021 - No Change, effective from 10/1/2020 through 9/30/2021
  • FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020
  • FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
  • FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
  • FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
  • FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016. This was the first year ICD-10-CM was implemented into the HIPAA code set.

Footnotes

[1] Not chronic - A diagnosis code that does not fit the criteria for chronic condition (duration, ongoing medical treatment, and limitations) is considered not chronic. Some codes designated as not chronic are acute conditions. Other diagnosis codes that indicate a possible chronic condition, but for which the duration of the illness is not specified in the code description (i.e., we do not know the condition has lasted 12 months or longer) also are considered not chronic.