Puncture wound with foreign body of breast
ICD-10 S21.04 is a billable code used to indicate a diagnosis of puncture wound with foreign body of breast.
A puncture wound with a foreign body of the breast typically occurs due to penetrating trauma, which can be caused by various objects such as needles, glass, or metal fragments. This type of injury can lead to complications such as infection, hematoma formation, or damage to underlying structures, including breast tissue and adjacent organs. In cases where the foreign body is not removed, there is a risk of chronic pain and potential for further complications. The management of such injuries often involves thorough assessment, imaging studies to locate the foreign body, and surgical intervention if necessary. Surgical procedures may include exploration and removal of the foreign body, drainage of any abscesses, and repair of any damaged tissue. The presence of a foreign body complicates the healing process and may require additional follow-up care to monitor for infection or other complications. Accurate coding of this condition is crucial for appropriate treatment planning and reimbursement.
Detailed operative notes describing the procedure, findings, and any complications.
Surgical removal of foreign bodies from the breast, management of infections, and repair of lacerations.
Ensure that all surgical interventions are documented, including imaging studies and consultations.
Comprehensive documentation of the initial assessment, imaging results, and treatment provided.
Assessment and stabilization of patients with puncture wounds, including foreign body retrieval.
Document the mechanism of injury and any immediate interventions performed.
Used when an abscess forms due to the puncture wound.
Document the size, location, and nature of the abscess.
General surgery may require additional documentation for surgical interventions.
Documenting the foreign body is crucial for accurate coding, treatment planning, and reimbursement. It helps to identify potential complications and guides the management of the injury.
