Laceration without foreign body of right breast
ICD-10 S21.011 is a billable code used to indicate a diagnosis of laceration without foreign body of right breast.
S21.011 refers to a laceration of the right breast that does not involve any foreign body. This type of injury can occur due to various mechanisms, including trauma from blunt or sharp objects, surgical procedures, or accidents. The clinical presentation may include pain, swelling, and bleeding at the site of the laceration. It is crucial to assess the extent of the injury, as lacerations can vary in depth and may involve underlying structures such as muscle or fat tissue. In cases of significant trauma, associated injuries such as rib fractures, pneumothorax, or hemothorax may also be present, necessitating a comprehensive evaluation. Proper management includes wound care, potential surgical intervention for deeper lacerations, and monitoring for complications. Accurate coding is essential for appropriate treatment reimbursement and tracking of trauma-related injuries.
Detailed description of the injury, mechanism of injury, and any associated injuries.
Patients presenting with trauma from accidents, falls, or assaults.
Ensure all associated injuries are documented to avoid undercoding.
Operative reports detailing the extent of the laceration and any surgical interventions performed.
Surgical repair of lacerations or management of complications from trauma.
Document the depth of the laceration and any involvement of underlying structures.
Used for repair of the laceration in the right breast.
Document the size and depth of the laceration.
Ensure the procedure aligns with the diagnosis for accurate billing.
S21.011 is used for lacerations without foreign bodies, while S21.012 is for lacerations that involve a foreign body. Accurate documentation is essential to determine which code to use.
