ICD 10 CM S36.49 | Description & Clinical Information

ICD 10 S36.49 describes a medical condition characterized by the occurrence of damage to the small intestine, which is the part of the digestive system that connects the stomach to the large bowel, resulting from blunt or penetrating trauma caused by various factors such as motor vehicle accidents, sports activities, falls, puncture or gunshot wounds, assault, or surgery, and is identified by healthcare providers as a specific type of injury to the small intestine that is not covered by any other codes in this category.

Official Description Of S36.49

The ICD 10 CM book defines ICD 10 code S36.49 as:

When To Use S36.49

The diagnosis describes by ICD-10-CM S36.49 code refers to an injury to the small intestine. The injury can occur due to trauma, such as blunt force or penetrating trauma, as well as non-traumatic causes such as infection, inflammation, or ischemia. This type of injury can lead to an array of symptoms that can range from mild to severe.

Some of the common symptoms reported by patients who have sustained an injury to the small intestine include abdominal pain or tenderness, spasm, swelling, bleeding, infection, slow or absent peristalsis, nausea, vomiting, fever, and chills. These symptoms can present themselves a few hours to a few days after the injury, and their severity and duration depend on the extent of the injury and its underlying cause.

To diagnose an injury to the small intestine, healthcare providers will start by conducting a thorough physical examination to assess the patient’s symptoms, medical history, and any other factors that may be contributing to their symptoms. Imaging tests such as X-rays, ultrasound, CT, color flow Doppler, and laparoscopy are often used to diagnose small intestine injuries, including assessing the extent of the injury and identifying any complications such as bowel obstruction or internal bleeding.

In some cases, laboratory evaluations such as blood tests may also be ordered to help diagnose the injury and evaluate the patient’s overall health status.

The severity of a small intestine injury often determines the treatment options available. In cases of severe injury or penetrating trauma, surgery may be required to repair or remove the damaged portion of the intestine. However, for less severe injuries, alternative treatments may include pain management strategies such as the use of analgesic medications, antibiotics for infections, and intravenous fluids or blood transfusions to manage fluid and electrolyte balances.

It is important for individuals who experience symptoms such as severe abdominal pain or who have sustained trauma to the abdomen to seek medical attention promptly. Early intervention and treatment can help to prevent complications such as internal bleeding or infection from developing.

In conclusion, while injuries to the small intestine can be painful and inconvenient, prompt diagnosis and appropriate treatment can help to manage symptoms and minimize complications. Medical coders must understand the codes for small intestine injuries and the importance of accurate medical coding to allow for effective treatment management and payment processing.