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ICD-10 Guide
ICD-10 CodesS31.23

S31.23

Billable

Puncture wound without foreign body of penis

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

Code Description

ICD-10 S31.23 is a billable code used to indicate a diagnosis of puncture wound without foreign body of penis.

Key Diagnostic Point:

A puncture wound of the penis is a type of injury characterized by a sharp object penetrating the skin and underlying tissues without the presence of a foreign body. This injury can occur due to various mechanisms, including accidents, self-inflicted injuries, or assault. Clinically, puncture wounds can lead to complications such as bleeding, infection, and damage to the underlying structures, including blood vessels and nerves. In the context of abdominal trauma, pelvic injuries, and genitourinary injuries, it is crucial to assess the extent of the injury and any associated damage to the surrounding organs. Emergency surgical interventions may be required to repair any lacerations, control bleeding, or prevent infection. Proper documentation of the mechanism of injury, the extent of the wound, and any surgical procedures performed is essential for accurate coding and billing.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation of injury mechanism
  • Potential for associated injuries in pelvic and abdominal regions
  • Need for detailed descriptions of surgical interventions
  • Differentiation from similar codes related to genital injuries

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to document associated injuries
  • Lack of clarity on surgical interventions performed
  • Misclassification of the injury type

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed descriptions of the injury, treatment provided, and any complications.

Common Clinical Scenarios

Management of puncture wounds, lacerations, and infections of the penis.

Billing Considerations

Consideration of potential urinary tract involvement and need for imaging studies.

Emergency Medicine

Documentation Requirements

Thorough documentation of the patient's history, mechanism of injury, and immediate treatment provided.

Common Clinical Scenarios

Acute management of trauma cases, including lacerations and puncture wounds.

Billing Considerations

Rapid assessment of associated injuries and potential need for surgical intervention.

Coding Guidelines

Inclusion Criteria

Use S31.23 When
  • According to ICD
  • 10 guidelines, S31
  • 23 should be used when a puncture wound of the penis is documented without the presence of a foreign body
  • It is essential to ensure that the documentation supports the diagnosis and any associated procedures

Exclusion Criteria

Do NOT use S31.23 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used when the puncture wound is repaired in an outpatient setting.

Documentation Requirements

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

Specialty Considerations

Urology specialists may need to provide additional details on the nature of the injury.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of injuries, including puncture wounds. This specificity helps in better tracking of injury types and outcomes, leading to improved patient care.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including puncture wounds. This specificity helps in better tracking of injury types and outcomes, leading to improved patient care.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of injuries, including puncture wounds. This specificity helps in better tracking of injury types and outcomes, leading to improved patient care.

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 S31.23 and S31.22?

S31.23 is used for puncture wounds without a foreign body, while S31.22 is for those with a foreign body present. Accurate documentation is essential to determine the correct code.