Open bite of trachea
ICD-10 S11.025 is a billable code used to indicate a diagnosis of open bite of trachea.
An open bite of the trachea refers to a penetrating injury that disrupts the integrity of the tracheal wall, often resulting from trauma such as a stab wound, gunshot, or severe blunt force. This injury can lead to significant airway compromise, potential for aspiration, and risk of infection. Clinically, patients may present with respiratory distress, stridor, or hemoptysis. Diagnosis typically involves imaging studies such as CT scans or bronchoscopy to assess the extent of the injury and any associated damage to surrounding structures. Management may require surgical intervention to repair the trachea, secure the airway, and prevent complications such as mediastinitis or tracheal stenosis. The prognosis depends on the severity of the injury, the timeliness of intervention, and the presence of any comorbid conditions.
Documentation must include a thorough assessment of the airway, vital signs, and any immediate interventions performed.
Trauma cases involving stabbings or gunshot wounds to the neck.
Rapid assessment and intervention are critical; ensure all findings are documented to support coding.
Operative reports should detail the surgical approach, repair techniques, and any complications encountered.
Surgical repair of tracheal injuries following trauma.
Ensure that all surgical findings and postoperative care are documented to support coding.
Used for evaluation of tracheal injury.
Document indications for bronchoscopy and findings.
Ensure that findings are clearly linked to the diagnosis of tracheal injury.
Used when specific procedures for tracheal repair are not listed.
Detailed operative report required.
Justify the use of unlisted codes with comprehensive documentation.
The primary mechanism is typically penetrating trauma, such as from a stab wound or gunshot, which disrupts the tracheal wall.
Open injuries involve a break in the skin and tracheal wall, while closed injuries do not penetrate the skin and are coded differently.
