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ICD-10 Guide
ICD-10 CodesS31.131

S31.131

Billable

Puncture wound of abdominal wall without foreign body, left upper quadrant without penetration into peritoneal cavity

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

Code Description

ICD-10 S31.131 is a billable code used to indicate a diagnosis of puncture wound of abdominal wall without foreign body, left upper quadrant without penetration into peritoneal cavity.

Key Diagnostic Point:

A puncture wound of the abdominal wall in the left upper quadrant indicates a breach in the skin and underlying tissues without the introduction of a foreign body and without penetration into the peritoneal cavity. This type of injury can occur due to various mechanisms, including accidental trauma from sharp objects or intentional injuries. Clinically, it is essential to assess the wound for signs of infection, bleeding, and damage to underlying structures such as muscles, nerves, and blood vessels. The absence of penetration into the peritoneal cavity is significant as it reduces the risk of intra-abdominal complications such as peritonitis or organ injury. Management typically involves wound care, possible suturing, and monitoring for complications. In emergency settings, a thorough evaluation is crucial to rule out associated injuries, especially in cases of abdominal trauma, where other organs may be affected. The left upper quadrant is anatomically significant as it houses vital organs, including the spleen and parts of the stomach, necessitating careful assessment and management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between types of abdominal injuries
  • Assessing for associated injuries in the left upper quadrant
  • Understanding the implications of non-penetrating versus penetrating wounds
  • Documentation of wound characteristics and treatment

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to specify the location of the wound accurately
  • Misclassification of the wound type (puncture vs. laceration)
  • Lack of follow-up documentation regarding wound care

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 stab wounds, accidental punctures, or sports-related injuries.

Billing Considerations

Ensure that all relevant anatomical structures are assessed and documented to avoid complications.

General Surgery

Documentation Requirements

Operative reports detailing the surgical intervention, if performed, and post-operative care.

Common Clinical Scenarios

Surgical repair of abdominal wall defects or management of complications from puncture wounds.

Billing Considerations

Documentation must reflect the surgical approach and any findings during the procedure.

Coding Guidelines

Inclusion Criteria

Use S31.131 When
  • Follow official ICD
  • CM coding guidelines, ensuring accurate documentation of the injury type, location, and any associated injuries

Exclusion Criteria

Do NOT use S31.131 When
  • Exclude codes for penetrating wounds or those involving foreign bodies

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used for suturing the puncture wound in the left upper quadrant.

Documentation Requirements

Document the size of the wound and the method of repair.

Specialty Considerations

Emergency medicine and surgical specialties should ensure accurate coding based on the complexity of the repair.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of injuries, improving the accuracy of data collection and reimbursement processes for puncture wounds.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, improving the accuracy of data collection and reimbursement processes for puncture wounds.

Reimbursement & Billing Impact

reimbursement processes for puncture wounds.

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 is the difference between S31.131 and S31.132?

S31.131 refers to a puncture wound without penetration into the peritoneal cavity, while S31.132 indicates a puncture wound with penetration into the peritoneal cavity, which carries a higher risk of complications.