05.01.10
May Question of the Month
Q: CT scan abdomen/pelvis - spleen normal; kidneys and adrenal glands normal; liver laceration gr IV injury - multiple deep lacerations. The patient is taken to OR where the operative note states liver laceration gr V injury. What would you code?
A: 541828.5; The surgeon is visually observing the liver and thus the operative grading is more accurate than the CT scan. An autopsy would also over-ride the reading of the CT if the grade is different.