Laceration without foreign body of unspecified breast
ICD-10 S21.019 is a billable code used to indicate a diagnosis of laceration without foreign body of unspecified breast.
S21.019 refers to a laceration of the breast tissue that does not involve any foreign body. This type of injury can occur due to various mechanisms, including trauma from blunt force, sharp objects, or surgical interventions. The breast is a complex structure composed of glandular tissue, adipose tissue, and connective tissue, making it susceptible to various types of injuries. Lacerations can lead to complications such as infection, hematoma formation, or scarring. In cases of significant trauma, associated injuries may include rib fractures, pneumothorax, or hemothorax, particularly if the trauma is severe enough to impact the thoracic cavity. Accurate coding of this condition is essential for proper treatment planning and reimbursement, as it may require surgical intervention or specialized care depending on the severity and extent of the laceration. Documentation should clearly describe the nature of the injury, any associated injuries, and the treatment provided to ensure appropriate coding and billing.
Detailed operative notes and descriptions of the laceration and any surgical interventions performed.
Surgical repair of breast lacerations following trauma or elective procedures.
Ensure that all associated injuries are documented to support coding for potential complications.
Comprehensive assessment notes including mechanism of injury, vital signs, and initial treatment provided.
Management of acute breast lacerations due to trauma or accidents.
Document any imaging studies performed to rule out associated thoracic injuries.
Used for suturing a laceration on the breast.
Operative notes detailing the size and location of the laceration.
General surgery documentation must include the rationale for the procedure.
Documentation should include the mechanism of injury, the extent of the laceration, any associated injuries, and the treatment provided. Clear notes will help justify the coding choice.
