Laceration without foreign body of abdominal wall, right upper quadrant without penetration into peritoneal cavity
ICD-10 S31.110 is a billable code used to indicate a diagnosis of laceration without foreign body of abdominal wall, right upper quadrant without penetration into peritoneal cavity.
S31.110 refers to a laceration of the abdominal wall located in the right upper quadrant, which does not involve any foreign body and does not penetrate the peritoneal cavity. This type of injury is often the result of blunt or penetrating trauma, such as from a fall, motor vehicle accident, or sharp object. Clinically, it is important to assess the depth and extent of the laceration, as well as to rule out any underlying organ damage, particularly to the liver, gallbladder, or kidneys, which are located in this quadrant. The absence of penetration into the peritoneal cavity suggests that the injury is superficial, but careful evaluation is necessary to ensure that there are no complications such as bleeding or infection. Treatment typically involves wound care, possible suturing, and monitoring for signs of complications. Accurate coding is essential for appropriate management and reimbursement.
Detailed documentation of the injury mechanism, assessment findings, and treatment provided.
Patients presenting with abdominal trauma from accidents or falls.
Ensure that all relevant imaging and lab results are documented to rule out internal injuries.
Operative reports detailing the laceration repair and any additional findings during surgery.
Surgical intervention for lacerations requiring suturing or exploration.
Document any findings related to underlying organ damage or complications.
Used for suturing a laceration in the right upper quadrant.
Document the size of the laceration and the method of repair.
Emergency medicine specialists should ensure that all relevant details of the injury and repair are documented.
Specifying 'without penetration into peritoneal cavity' is crucial as it indicates the severity of the injury and helps in determining the appropriate treatment and coding. It differentiates this laceration from more severe injuries that may require surgical intervention.
