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ICD-10 Guide
ICD-10 CodesS31.60

S31.60

Billable

Unspecified open wound of abdominal wall with penetration into peritoneal cavity

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

Code Description

ICD-10 S31.60 is a billable code used to indicate a diagnosis of unspecified open wound of abdominal wall with penetration into peritoneal cavity.

Key Diagnostic Point:

An unspecified open wound of the abdominal wall with penetration into the peritoneal cavity indicates a traumatic injury where the abdominal wall has been breached, allowing for potential exposure of internal organs to external contaminants. This type of injury often results from blunt or penetrating trauma, such as stab wounds, gunshot wounds, or severe blunt force impacts. The peritoneal cavity houses vital organs, including the intestines, liver, and spleen, making such injuries critical and requiring immediate medical attention. Symptoms may include abdominal pain, distension, and signs of peritonitis. Emergency surgical intervention is often necessary to repair the wound, assess for organ damage, and prevent infection. The complexity of managing these injuries lies in the need for thorough assessment and potential multi-organ involvement, which can complicate both diagnosis and treatment.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Variability in injury severity and organ involvement
  • Need for immediate surgical intervention
  • Potential for complications such as infection or hemorrhage
  • Documentation of trauma mechanism and clinical findings

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to document surgical interventions performed
  • Misclassification of wound type or severity
  • Lack of follow-up documentation on patient outcomes

Specialty Focus

Medical Specialties

Trauma Surgery

Documentation Requirements

Detailed operative reports, imaging studies, and notes on patient assessment and management.

Common Clinical Scenarios

Management of stab wounds, gunshot wounds, and blunt abdominal trauma.

Billing Considerations

Accurate documentation of the extent of injury and any associated organ damage is crucial for coding.

Emergency Medicine

Documentation Requirements

Comprehensive triage notes, initial assessment findings, and treatment protocols.

Common Clinical Scenarios

Initial evaluation and stabilization of trauma patients with abdominal injuries.

Billing Considerations

Timely documentation of vital signs and interventions is essential for accurate coding.

Coding Guidelines

Inclusion Criteria

Use S31.60 When
  • According to ICD
  • 10 coding guidelines, this code should be used when there is an open wound of the abdominal wall with confirmed penetration into the peritoneal cavity
  • Coders must ensure that documentation supports the diagnosis and that any associated injuries are coded appropriately

Exclusion Criteria

Do NOT use S31.60 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

49000CPT Code

Exploratory Laparotomy

Clinical Scenario

Used in cases of penetrating abdominal trauma to assess and repair injuries.

Documentation Requirements

Operative report detailing findings and interventions.

Specialty Considerations

Trauma surgeons must document the extent of injury and any repairs performed.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of abdominal injuries, improving the accuracy of data collection and reimbursement processes. S31.60 provides a clear designation for open wounds with peritoneal involvement, which was less specific in ICD-9.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of abdominal injuries, improving the accuracy of data collection and reimbursement processes. S31.60 provides a clear designation for open wounds with peritoneal involvement, which was less specific in ICD-9.

Reimbursement & Billing Impact

reimbursement processes. S31.60 provides a clear designation for open wounds with peritoneal involvement, which was less specific in ICD-9.

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 S31.60 and S31.61?

S31.60 refers to an unspecified open wound of the abdominal wall with penetration into the peritoneal cavity, while S31.61 specifies an open wound that is superficial without penetration.