Puncture wound with foreign body of lower back and pelvis
ICD-10 S31.04 is a billable code used to indicate a diagnosis of puncture wound with foreign body of lower back and pelvis.
A puncture wound with a foreign body in the lower back and pelvis is a specific type of injury that occurs when an object penetrates the skin and underlying tissues in these regions. This type of injury can result from various incidents, including accidents, falls, or assaults. The presence of a foreign body complicates the injury, as it may lead to infection, tissue damage, or further complications if not properly addressed. Clinically, patients may present with localized pain, swelling, and signs of infection such as redness or discharge. Imaging studies, such as X-rays or CT scans, may be necessary to locate the foreign object and assess any associated injuries to the lumbar spine, pelvic structures, or surrounding organs, including the genitourinary system. Emergency surgical intervention may be required to remove the foreign body, repair any damaged tissues, and prevent complications. The management of such injuries often involves a multidisciplinary approach, including trauma surgeons, urologists, and orthopedic specialists, depending on the extent of the injury and the structures involved.
Detailed operative notes, imaging results, and post-operative care plans.
Gunshot wounds, stab wounds, or accidental punctures with foreign objects.
Ensure all associated injuries are documented to support coding.
Urological assessments, imaging studies, and surgical notes if urological structures are involved.
Injuries involving the bladder or urethra due to foreign bodies.
Document any urological complications or interventions performed.
Used when a puncture wound requires closure without extensive intervention.
Document the size and location of the wound, as well as the method of repair.
Trauma surgeons should ensure that all associated injuries are documented.
The primary focus is to accurately document the presence of a foreign body and any associated injuries to ensure appropriate coding and billing.
