Puncture wound without foreign body of right breast
ICD-10 S21.031 is a billable code used to indicate a diagnosis of puncture wound without foreign body of right breast.
A puncture wound of the right breast is a type of injury characterized by a sharp object penetrating the skin and underlying tissues without the presence of a foreign body. This injury can occur due to various mechanisms, including accidental trauma, self-inflicted wounds, or as a result of a medical procedure. Clinically, puncture wounds can lead to complications such as infection, hematoma formation, or damage to underlying structures, including breast tissue and adjacent muscles. In the context of chest trauma, it is crucial to assess for associated injuries such as rib fractures, pneumothorax, or hemothorax, which may arise from penetrating injuries to the thoracic cavity. Cardiac injuries may also be a concern if the puncture wound is deep enough to compromise the pericardium or myocardium. Surgical interventions may be required to manage complications or repair damaged tissues, emphasizing the importance of thorough documentation and accurate coding to reflect the complexity of care provided.
Detailed account of the injury mechanism, assessment of associated injuries, and treatment provided.
Patients presenting with puncture wounds from accidents, self-harm, or medical procedures.
Ensure that all associated injuries are documented to support the complexity of care.
Operative reports detailing the extent of the injury, any surgical interventions performed, and post-operative care.
Surgical repair of puncture wounds or management of complications such as pneumothorax.
Accurate coding of surgical procedures related to the injury is essential.
Used for repair of the puncture wound if surgical intervention is required.
Operative report detailing the repair procedure.
Ensure that the procedure is linked to the diagnosis of the puncture wound.
A puncture wound is caused by a sharp object penetrating the skin, while a laceration is a tear or cut in the skin that may involve deeper tissues. Puncture wounds are typically more narrow and can be deeper than they appear, often requiring different management.
