Unspecified open wound of breast
ICD-10 S21.00 is a billable code used to indicate a diagnosis of unspecified open wound of breast.
An unspecified open wound of the breast refers to a traumatic injury that results in a break in the skin and underlying tissues of the breast without a specific description of the wound type. This can occur due to various mechanisms of injury, including blunt or penetrating trauma. In the context of chest trauma, such wounds may be associated with rib fractures, pneumothorax, or hemothorax, particularly in cases of significant blunt force trauma. The breast tissue is highly vascular, and injuries can lead to substantial bleeding or complications such as infection. Additionally, cardiac injuries may occur in severe cases, necessitating careful evaluation and management. Surgical interventions may be required to repair the wound, control bleeding, or address any underlying thoracic injuries. Accurate coding of this condition is essential for proper treatment documentation and reimbursement, as it may impact the overall management of chest trauma patients.
Detailed account of the mechanism of injury, vital signs, and initial treatment provided.
Patients presenting with trauma from accidents, falls, or assaults resulting in breast injuries.
Ensure documentation includes any associated thoracic injuries or interventions performed.
Operative reports detailing the nature of the wound, surgical interventions, and post-operative care.
Surgical repair of breast wounds following trauma or elective procedures.
Document any complications or additional procedures performed during surgery.
Used in cases where surgical intervention is required for open wounds.
Operative report detailing the procedure and indications.
General surgery documentation must include pre-operative assessments.
Document the mechanism of injury, the extent of the wound, any associated injuries, and the treatment provided to ensure accurate coding.
