Unspecified open wound of abdominal wall, right lower quadrant without penetration into peritoneal cavity
ICD-10 S31.103 is a billable code used to indicate a diagnosis of unspecified open wound of abdominal wall, right lower quadrant without penetration into peritoneal cavity.
An unspecified open wound of the abdominal wall in the right lower quadrant indicates a traumatic injury that has resulted in a break in the skin and underlying tissues without breaching the peritoneal cavity. This type of injury may arise from blunt or penetrating trauma, such as falls, motor vehicle accidents, or sharp object injuries. The right lower quadrant of the abdomen houses vital organs, including parts of the intestines, the appendix, and the right ovary in females. Although the wound does not penetrate the peritoneal cavity, it can still lead to significant complications, including infection, hemorrhage, or damage to surrounding structures. Emergency surgical intervention may be required to manage the wound, assess for any associated injuries, and prevent further complications. Proper documentation of the mechanism of injury, the extent of the wound, and any associated injuries is crucial for accurate coding and treatment planning.
Detailed description of the injury mechanism, assessment of vital signs, and any immediate interventions performed.
Patients presenting with abdominal trauma from accidents, falls, or assaults.
Ensure that all associated injuries are documented, as they may affect treatment and coding.
Operative reports detailing the surgical approach, findings, and any repairs performed.
Surgical intervention for open abdominal wounds, including exploration and repair.
Document any findings related to adjacent organs to support coding for additional injuries.
Used for the repair of the open wound in the right lower quadrant.
Document the size and depth of the wound, as well as the method of repair.
Emergency medicine and surgical specialties should ensure accurate coding based on the complexity of the repair.
Documentation should include the mechanism of injury, the size and depth of the wound, any associated injuries, and the treatment provided.
