Open bite of penis
ICD-10 S31.25 is a billable code used to indicate a diagnosis of open bite of penis.
An open bite of the penis is a traumatic injury characterized by a laceration or puncture wound that penetrates the skin and underlying tissues of the penile shaft. This type of injury can occur due to various mechanisms, including animal bites, human bites, or accidents involving sharp objects. The clinical presentation may include bleeding, swelling, and pain at the site of injury, and there may be associated injuries to the surrounding structures, such as the urethra or scrotum. Open bites can lead to complications such as infection, scarring, and functional impairment if not properly managed. Emergency evaluation typically involves a thorough physical examination, assessment of the extent of the injury, and imaging studies if necessary to rule out deeper tissue damage. Surgical intervention may be required for wound debridement, repair of any lacerated structures, and to prevent infection. Proper coding for this injury is crucial for accurate medical billing and to ensure appropriate treatment protocols are followed.
Detailed notes on the nature of the injury, any associated urethral injuries, and surgical interventions performed.
Management of open bites resulting from animal attacks or human altercations, including repair of lacerations and assessment for urethral injury.
Urologists must ensure that any potential urethral injury is documented and assessed, as this can significantly impact treatment and coding.
Comprehensive assessment of the injury, including mechanism, extent, and initial management steps taken.
Initial evaluation and stabilization of patients with open bites, including wound care and referral to specialists.
Emergency physicians should document the patient's vital signs and any immediate interventions to support coding for the level of care provided.
Used for the repair of an open bite of the penis that does not involve deeper structures.
Document the size of the wound and the method of repair.
Urologists may perform more complex repairs depending on the extent of the injury.
May be relevant if the injury necessitates circumcision due to extensive damage.
Document the reason for circumcision and any associated injuries.
Urologists should ensure that the indication for the procedure is clearly documented.
The primary documentation needed includes a detailed description of the injury, the mechanism of injury, any associated injuries, and the treatment provided. This ensures accurate coding and appropriate reimbursement.
