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ICD-10 Guide
ICD-10 CodesS31.10

S31.10

Billable

Unspecified open wound of abdominal wall without penetration into peritoneal cavity

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

Code Description

ICD-10 S31.10 is a billable code used to indicate a diagnosis of unspecified open wound of abdominal wall without penetration into peritoneal cavity.

Key Diagnostic Point:

An unspecified open wound of the abdominal wall refers to a traumatic injury that results in a break in the skin and underlying tissues of the abdominal area, without involving the peritoneal cavity. This type of injury can occur due to various mechanisms, including blunt trauma, penetrating injuries, or surgical complications. The abdominal wall consists of multiple layers, including skin, subcutaneous tissue, fascia, and muscle, and injuries can vary in severity from superficial lacerations to deeper wounds affecting muscle and fascia. Clinical assessment is crucial to determine the extent of the injury, the need for surgical intervention, and to rule out associated injuries to internal organs. Emergency management may involve wound cleaning, suturing, and monitoring for signs of infection or complications. Accurate coding is essential for appropriate treatment planning and reimbursement, as well as for tracking injury patterns in trauma registries.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in injury presentation and severity
  • Need for detailed documentation of wound characteristics
  • Differentiation from other abdominal injuries
  • Potential for associated internal injuries

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to specify the depth of the wound
  • Misclassification of the injury type
  • Lack of follow-up documentation on treatment outcomes

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Detailed description of the injury mechanism, assessment findings, and treatment provided.

Common Clinical Scenarios

Patients presenting with abdominal trauma from accidents, falls, or assaults.

Billing Considerations

Ensure that all associated injuries are documented to avoid undercoding.

General Surgery

Documentation Requirements

Operative reports detailing the extent of the wound and any surgical interventions performed.

Common Clinical Scenarios

Patients requiring surgical repair of abdominal wall injuries.

Billing Considerations

Document any complications or additional procedures performed during surgery.

Coding Guidelines

Inclusion Criteria

Use S31.10 When
  • According to ICD
  • CM guidelines, this code should be used when the specific nature of the open wound is not documented
  • Coders should ensure that the injury does not involve penetration into the peritoneal cavity, as this would require a different code

Exclusion Criteria

Do NOT use S31.10 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used for suturing a superficial open wound of the abdominal wall.

Documentation Requirements

Document the size and location of the wound, and the technique used.

Specialty Considerations

Emergency medicine and general surgery may both utilize this code.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of abdominal injuries, improving the granularity of data for tracking and treatment outcomes. S31.10 provides a clear designation for unspecified open wounds, facilitating appropriate management and reimbursement.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of abdominal injuries, improving the granularity of data for tracking and treatment outcomes. S31.10 provides a clear designation for unspecified open wounds, facilitating appropriate management and reimbursement.

Reimbursement & Billing Impact

reimbursement.

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 should I document to support the use of S31.10?

Document the mechanism of injury, the depth and extent of the wound, any associated injuries, and the treatment provided. This information is crucial for accurate coding and reimbursement.