A: The correct code is 856173.5. The blood loss of >20% will probably not be found clearly documented in the chart, since physicians do not want to disturb the hematoma and rarely estimate its volume. However, the extensive fractures and the shift of the urinary bladder are objective signs that can be used to estimate that blood loss has been substantial. As always, if the signs are “soft” and the coder is unsure about blood loss, s/he should code more conservatively, but in this case, it is safe to “assume” the blood loss.

X