The patient, who is status post placement of a cardiac pacemaker, presents for pacemaker revision due to the right atrial and ventricular leads not sensing properly. After the right atrial lead was extracted, the surgeon noted a large pericardial effusion. A sternotomy was then performed; the pericardium was opened; and blood was removed. A laceration of the right atrial appendage was found and repaired with suture. What is the appropriate ICD-10-CM code assignment for intraoperative laceration of the right atrial appendage with hemopericardium? Is a traumatic injury code appropriate?
Assign code I97.51, Accidental puncture and laceration of a circulatory system organ or structure during a circulatory system procedure, for the intraoperative complication. Assign also code Y65.8, Other specified misadventures during surgical and medical care, to capture the external cause. Traumatic injury codes should not be assigned for injuries that occur during, or as a result of, a medical intervention.