ICD-10 Code D78.11 – Accidental puncture and laceration of the spleen during a procedure on the spleen (2026): Diagnosis, Symptoms & Billing Guide
2026 ICD-10-CM Diagnosis Code D78.11 – Accidental puncture and laceration of the spleen during a procedure on the spleen
What it is
D78.11 identifies an accidental puncture or laceration of the spleen that occurs during a procedure on the spleen. Use it when the injury is documented as an unintended operative complication, not as the planned result of surgery.
Clinical signs
Clinical features vary; refer to documentation. Typical findings may include intraoperative recognition of splenic injury, bleeding, or a note describing repair of an unintended splenic tear during the procedure.
When to use this code
Use this code when the record clearly states that the spleen was punctured or lacerated accidentally during a procedure on the spleen. It is appropriate for operative complications documented by the surgeon or in the procedure note. If the chart does not specify accidental injury, check documentation.
Do not use for
Do not use this code for a planned splenic resection, biopsy, or other intentional surgical manipulation. It also should not be used when the spleen injury occurred outside the procedure or when the documentation is unclear.
Coding tip
Code only when the operative report explicitly links the splenic injury to the procedure and describes it as accidental.