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v1.0.0
ICD-10 Guide
ICD-10 CodesS31.623

S31.623

Billable

Laceration with foreign body of abdominal wall, right lower quadrant with penetration into peritoneal cavity

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/23/2025

Code Description

ICD-10 S31.623 is a billable code used to indicate a diagnosis of laceration with foreign body of abdominal wall, right lower quadrant with penetration into peritoneal cavity.

Key Diagnostic Point:

S31.623 describes a traumatic injury characterized by a laceration in the abdominal wall located specifically in the right lower quadrant, which has been complicated by the presence of a foreign body that has penetrated into the peritoneal cavity. This type of injury often results from penetrating trauma, such as stab wounds or gunshot wounds, and can lead to significant complications, including peritonitis, hemorrhage, and damage to internal organs such as the intestines or bladder. The right lower quadrant is anatomically significant as it houses structures such as the appendix, cecum, and portions of the small intestine. The presence of a foreign body complicates the clinical picture, necessitating careful evaluation and often surgical intervention to remove the foreign object and repair any damage to the abdominal wall and underlying structures. Emergency surgical intervention is typically required to address the laceration and prevent further complications, making this a critical condition that requires immediate medical attention.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Presence of a foreign body complicates the injury.
  • Potential for multiple organ involvement increases coding complexity.
  • Need for precise documentation of the injury's extent and location.
  • Emergency surgical intervention may involve multiple procedures.

Audit Risk Factors

  • Inadequate documentation of the foreign body and its impact on treatment.
  • Failure to document the extent of the laceration.
  • Misclassification of the injury type (e.g., laceration vs. puncture).
  • Lack of clarity on the surgical procedures performed.

Specialty Focus

Medical Specialties

Trauma Surgery

Documentation Requirements

Detailed operative reports and imaging studies to confirm the extent of injury.

Common Clinical Scenarios

Management of stab wounds or gunshot wounds to the abdomen.

Billing Considerations

Accurate documentation of the mechanism of injury and any associated injuries.

Emergency Medicine

Documentation Requirements

Thorough initial assessment notes and triage documentation.

Common Clinical Scenarios

Acute presentations of abdominal trauma in the emergency department.

Billing Considerations

Timely documentation of vital signs and interventions performed.

Coding Guidelines

Inclusion Criteria

Use S31.623 When
  • According to ICD
  • CM guidelines, S31
  • 623 should be used when there is a documented laceration with a foreign body that has penetrated the peritoneal cavity
  • Coders must ensure that the documentation supports the diagnosis and that all relevant details are captured

Exclusion Criteria

Do NOT use S31.623 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

49002CPT Code

Exploratory laparotomy, with or without repair of laceration

Clinical Scenario

Used when surgical intervention is required for laceration repair.

Documentation Requirements

Operative report detailing the procedure and findings.

Specialty Considerations

Trauma surgeons must document the mechanism of injury and any associated procedures.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of traumatic injuries, such as S31.623, which provides better data for tracking and managing trauma cases. This specificity aids in clinical decision-making and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of traumatic injuries, such as S31.623, which provides better data for tracking and managing trauma cases. This specificity aids in clinical decision-making and resource allocation.

Reimbursement & Billing Impact

reimbursement.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What is the significance of coding S31.623 accurately?

Accurate coding of S31.623 is crucial for proper reimbursement, tracking of trauma cases, and ensuring appropriate clinical management of patients with complex abdominal injuries.