Puncture wound without foreign body of breast
ICD-10 S21.03 is a billable code used to indicate a diagnosis of puncture wound without foreign body of breast.
A puncture wound of the breast is characterized by a sharp object penetrating the skin and underlying tissues without the presence of a foreign body. This type of injury can occur due to various mechanisms, including trauma from sharp objects, accidental injuries, or even self-inflicted wounds. Clinically, puncture wounds can lead to complications such as infection, hematoma formation, or damage to underlying structures, including breast tissue and ducts. In the context of chest trauma, puncture wounds may also be associated with rib fractures, pneumothorax, or hemothorax, especially if the injury is severe. It is crucial for healthcare providers to assess the extent of the injury, perform imaging studies if necessary, and monitor for any signs of complications. Surgical intervention may be required in cases where there is significant damage or if the wound becomes infected. Accurate coding of this condition is essential for proper treatment documentation and reimbursement.
Detailed description of the injury mechanism, assessment of associated injuries, and treatment provided.
Patients presenting with puncture wounds from accidents, assaults, or self-harm.
Consideration of potential complications such as infection or internal injuries.
Surgical notes detailing the extent of the injury, any foreign body removal, and post-operative care.
Surgical intervention for infected puncture wounds or significant tissue damage.
Documentation of surgical findings and any additional procedures performed.
Used for repair of the puncture wound if suturing is required.
Detailed description of the wound and repair performed.
Emergency medicine or surgical notes should clearly document the procedure.
S21.03 is used for puncture wounds without foreign bodies, while S21.01 is for those with foreign bodies present. Accurate documentation is crucial to determine which code to use.
