Laceration without foreign body of right front wall of thorax without penetration into thoracic cavity
ICD-10 S21.111 is a billable code used to indicate a diagnosis of laceration without foreign body of right front wall of thorax without penetration into thoracic cavity.
S21.111 refers to a laceration on the right front wall of the thorax that does not involve any foreign body and does not penetrate the thoracic cavity. This type of injury is often the result of blunt or sharp trauma, such as a fall, motor vehicle accident, or an assault. Clinically, it is important to assess the extent of the laceration, as well as to rule out associated injuries such as rib fractures, pneumothorax, or hemothorax. Rib fractures can occur due to the force of the trauma, leading to potential complications like pneumothorax (air in the pleural space) or hemothorax (blood in the pleural space). Cardiac injuries may also be a concern, particularly in high-impact trauma cases. Surgical intervention may be required for extensive lacerations or if there is a risk of underlying organ damage. Proper documentation of the injury's location, depth, and any associated injuries is crucial for accurate coding and treatment planning.
Detailed description of the mechanism of injury, assessment of vital signs, and any imaging studies performed.
Patients presenting with chest trauma from accidents, falls, or assaults.
Ensure that all associated injuries are documented, and that the treatment plan is clearly outlined.
Operative reports detailing the surgical approach, findings, and any repairs made.
Patients requiring surgical intervention for extensive lacerations or associated injuries.
Document the extent of the laceration and any complications that arise during surgery.
Used for laceration repair in the emergency department.
Document the size and location of the laceration, as well as the repair technique used.
Emergency medicine providers should ensure that all details of the injury and repair are accurately captured.
S21.111 is used for lacerations without foreign bodies, while S21.112 is for lacerations that involve foreign bodies. Accurate documentation is essential to determine which code to use.
