ICD-10 Code D78.1 – Accidental puncture and laceration of the spleen during a procedure (2026): Diagnosis, Symptoms & Billing Guide
2026 ICD-10-CM Diagnosis Code D78.1 – Accidental puncture and laceration of the spleen during a procedure
What it is
This code identifies an unintended injury to the spleen that occurs during a medical procedure. Use it when the documentation clearly states the splenic puncture or laceration was accidental and procedure-related.
Clinical signs
Clinical features may include abdominal pain, tenderness, or signs of internal bleeding after a procedure. Clinical features vary; refer to documentation.
When to use this code
Use D78.1 when the provider documents an accidental splenic puncture or laceration caused during surgery, endoscopy, or another intervention. The record should link the injury to the procedure and identify the spleen as the affected organ. If the note is unclear, check documentation.
Do not use for
Do not use this code for traumatic spleen injury from an external accident or for a planned splenic procedure. It is also not appropriate when the record does not specify an accidental procedural cause.
Coding tip
Verify that the injury is described as accidental and procedure-related before assigning D78.1.