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ICD-10 Guide
ICD-10 CodesS21.212

S21.212

Billable

Laceration without foreign body of left back wall of thorax without penetration into thoracic cavity

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/23/2025

Code Description

ICD-10 S21.212 is a billable code used to indicate a diagnosis of laceration without foreign body of left back wall of thorax without penetration into thoracic cavity.

Key Diagnostic Point:

S21.212 refers to a laceration on the left back wall of the thorax that does not involve a foreign body and does not penetrate the thoracic cavity. This type of injury is often the result of blunt or penetrating trauma, such as falls, motor vehicle accidents, or assaults. Clinically, it is important to assess the extent of the laceration and any associated injuries, such as rib fractures, pneumothorax, or hemothorax. While the laceration itself may not penetrate the thoracic cavity, the potential for underlying injuries necessitates thorough evaluation. Rib fractures can occur in conjunction with such lacerations, leading to 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 interventions may be required to repair the laceration or address any associated injuries, emphasizing the need for accurate coding to reflect the complexity of the patient's condition and treatment.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Need for detailed documentation of the injury's location and extent
  • Assessment of associated injuries (e.g., rib fractures, pneumothorax)
  • Differentiation from similar codes for thoracic injuries
  • Potential for surgical intervention and its documentation

Audit Risk Factors

  • Inadequate documentation of the injury's specifics
  • Failure to document associated injuries
  • Misclassification of the type of laceration
  • Lack of clarity on whether the injury penetrated the thoracic cavity

Specialty Focus

Medical Specialties

Trauma Surgery

Documentation Requirements

Detailed descriptions of the injury, mechanism of injury, and any surgical interventions performed.

Common Clinical Scenarios

Management of traumatic lacerations, rib fractures, and associated thoracic injuries.

Billing Considerations

Ensure all associated injuries are documented to support coding for potential surgical interventions.

Emergency Medicine

Documentation Requirements

Thorough assessment notes, including vital signs, imaging results, and treatment provided.

Common Clinical Scenarios

Initial evaluation and stabilization of trauma patients with thoracic injuries.

Billing Considerations

Accurate documentation of the mechanism of injury and any immediate interventions performed.

Coding Guidelines

Inclusion Criteria

Use S21.212 When
  • Follow official coding guidelines for trauma injuries, ensuring accurate documentation of the injury's specifics and any associated conditions
  • Include details about the mechanism of injury and any treatments provided

Exclusion Criteria

Do NOT use S21.212 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

12002CPT Code

Simple repair of a laceration

Clinical Scenario

Used when the laceration requires repair but does not involve deeper structures.

Documentation Requirements

Document the size and depth of the laceration, as well as the repair technique used.

Specialty Considerations

Trauma surgeons should ensure that the repair is well-documented to support the coding.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of thoracic injuries, improving the accuracy of data collection and reimbursement processes. S21.212 provides a clear distinction between types of lacerations, which aids in clinical management and research.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of thoracic injuries, improving the accuracy of data collection and reimbursement processes. S21.212 provides a clear distinction between types of lacerations, which aids in clinical management and research.

Reimbursement & Billing Impact

reimbursement processes. S21.212 provides a clear distinction between types of lacerations, which aids in clinical management and research.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What is the significance of coding S21.212 accurately?

Accurate coding of S21.212 is crucial for proper reimbursement, tracking of trauma cases, and ensuring appropriate clinical management. It helps in identifying trends in thoracic injuries and facilitates research into treatment outcomes.