Laceration without foreign body of trachea
ICD-10 S11.021 is a billable code used to indicate a diagnosis of laceration without foreign body of trachea.
S11.021 refers to a laceration of the trachea that occurs without the presence of a foreign body. This type of injury can result from various mechanisms, including blunt trauma, penetrating trauma, or surgical complications. Clinically, patients may present with symptoms such as difficulty breathing, stridor, or subcutaneous emphysema. Diagnosis typically involves imaging studies such as CT scans or bronchoscopy to assess the extent of the injury. Management may include surgical intervention to repair the laceration, especially if there is significant airway compromise. The absence of a foreign body is crucial in differentiating this code from other tracheal injuries that may involve foreign objects. Accurate coding is essential for appropriate treatment and reimbursement, as well as for tracking injury patterns and outcomes in trauma care.
Documentation should include a detailed account of the mechanism of injury, vital signs, and any immediate interventions performed.
Trauma from motor vehicle accidents, falls, or assaults where the trachea may be compromised.
Emergency providers must ensure that all findings are documented clearly to support the diagnosis and coding.
Operative reports must detail the surgical approach, findings, and any repairs made to the trachea.
Surgical repair of tracheal lacerations following trauma or during procedures involving the neck.
Surgeons should document the extent of the laceration and any associated injuries to ensure accurate coding.
Used in cases of airway compromise due to laceration.
Document the need for intubation and the patient's condition.
Emergency medicine providers should ensure clear documentation of the airway status.
S11.021 is used for lacerations of the trachea without foreign bodies, while S11.022 is for lacerations that involve foreign bodies. Accurate documentation is essential to determine which code to use.
