Laceration without foreign body of right front wall of thorax with penetration into thoracic cavity
ICD-10 S21.311 is a billable code used to indicate a diagnosis of laceration without foreign body of right front wall of thorax with penetration into thoracic cavity.
S21.311 refers to a laceration of the right front wall of the thorax that penetrates into the thoracic cavity but does not involve a foreign body. This type of injury is often the result of blunt or penetrating trauma, such as from a knife or a gunshot wound. The thoracic cavity houses vital organs, including the lungs and heart, making such injuries potentially life-threatening. Complications may include pneumothorax (air in the pleural space), hemothorax (blood in the pleural space), rib fractures, and cardiac injuries. Immediate medical intervention is crucial to assess the extent of the injury, manage any associated complications, and determine the need for surgical intervention. Surgical procedures may involve thoracotomy or video-assisted thoracoscopic surgery (VATS) to repair the laceration and address any damage to the underlying structures. Proper documentation of the mechanism of injury, clinical findings, and treatment provided is essential for accurate coding and billing.
Detailed operative reports, imaging studies, and notes on the mechanism of injury.
Management of penetrating trauma, rib fractures, and thoracic cavity injuries.
Accurate documentation of surgical procedures and post-operative care is critical for coding.
Comprehensive assessment notes, including vital signs and initial management.
Initial evaluation and stabilization of patients with thoracic injuries.
Timely documentation is essential to capture the acute nature of the injury.
Used to drain fluid or air from the pleural space in cases of hemothorax or pneumothorax.
Document the indication for the procedure and the amount of fluid drained.
Emergency medicine and pulmonology may frequently perform this procedure.
S21.311 is used for lacerations without foreign bodies, while S21.312 is for lacerations that involve a foreign body. Accurate documentation is essential to determine which code to use.
