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ICD-10 Guide
ICD-10 CodesS21.43

S21.43

Billable

Puncture wound without foreign body of back wall of thorax with penetration into thoracic cavity

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

Code Description

ICD-10 S21.43 is a billable code used to indicate a diagnosis of puncture wound without foreign body of back wall of thorax with penetration into thoracic cavity.

Key Diagnostic Point:

A puncture wound of the back wall of the thorax that penetrates into the thoracic cavity can result from various traumatic incidents, including stab wounds, gunshot wounds, or accidental injuries. This type of injury can lead to significant complications such as pneumothorax, hemothorax, or damage to thoracic organs, including the lungs and heart. The clinical presentation may include respiratory distress, chest pain, and signs of shock. Diagnosis typically involves imaging studies such as chest X-rays or CT scans to assess the extent of the injury and any associated complications. Management may require surgical intervention, such as thoracotomy or chest tube placement, to address bleeding or air leaks. Close monitoring is essential to prevent further complications and ensure proper recovery.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Requires detailed documentation of the mechanism of injury.
  • Assessment of associated injuries (e.g., rib fractures, pneumothorax).
  • Potential for multiple interventions and complications.
  • Need for accurate coding of any surgical procedures performed.

Audit Risk Factors

  • Inadequate documentation of the injury mechanism.
  • Failure to document associated injuries.
  • Incorrect coding of surgical interventions.
  • Lack of follow-up documentation on patient outcomes.

Specialty Focus

Medical Specialties

Trauma Surgery

Documentation Requirements

Detailed operative reports and imaging studies.

Common Clinical Scenarios

Management of stab wounds or gunshot injuries to the thorax.

Billing Considerations

Ensure documentation reflects the severity and complexity of the injury.

Pulmonology

Documentation Requirements

Pulmonary function tests and imaging results.

Common Clinical Scenarios

Management of pneumothorax or hemothorax following thoracic trauma.

Billing Considerations

Document any respiratory complications and interventions.

Coding Guidelines

Inclusion Criteria

Use S21.43 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the injury's nature, location, and any associated complications
  • Include details of any surgical procedures performed

Exclusion Criteria

Do NOT use S21.43 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

32000CPT Code

Thoracentesis

Clinical Scenario

Used for drainage of pleural effusion or hemothorax.

Documentation Requirements

Document indication for procedure and findings.

Specialty Considerations

Pulmonology may require additional pulmonary function tests.

32010CPT Code

Tube thoracostomy

Clinical Scenario

Indicated for pneumothorax or hemothorax management.

Documentation Requirements

Document the indication, procedure details, and post-procedure status.

Specialty Considerations

Trauma surgery may involve complex decision-making.

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. This specificity aids in better tracking of patient outcomes and resource utilization.

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. This specificity aids in better tracking of patient outcomes and resource utilization.

Reimbursement & Billing Impact

reimbursement processes. This specificity aids in better tracking of patient outcomes and resource utilization.

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 are the common complications associated with S21.43?

Common complications include pneumothorax, hemothorax, and potential injury to thoracic organs such as the lungs and heart, which may require surgical intervention.