Laceration without foreign body of abdominal wall with penetration into peritoneal cavity
ICD-10 S31.61 is a billable code used to indicate a diagnosis of laceration without foreign body of abdominal wall with penetration into peritoneal cavity.
S31.61 refers to a specific type of abdominal wall injury characterized by a laceration that penetrates the peritoneal cavity but does not involve any foreign body. This condition often arises from blunt or penetrating trauma, such as stab wounds or accidents involving sharp objects. The peritoneal cavity houses vital organs, including the intestines, liver, and spleen, making such injuries potentially life-threatening. Clinically, patients may present with abdominal pain, signs of peritonitis, or even shock due to internal bleeding. Emergency surgical intervention is frequently required to repair the laceration and address any damage to internal organs. 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. Accurate coding is essential for proper reimbursement and tracking of trauma cases in healthcare settings.
Detailed operative reports, including descriptions of the laceration and any repairs performed.
Patients presenting with stab wounds, gunshot wounds, or blunt trauma leading to abdominal wall lacerations.
Ensure that all findings during surgery are documented, including any organ involvement or complications.
Comprehensive initial assessment notes, including vital signs, imaging results, and treatment provided.
Patients arriving at the emergency department with acute abdominal pain and signs of trauma.
Accurate documentation of the mechanism of injury and any immediate interventions performed.
Used when surgical exploration is required for abdominal trauma.
Operative report detailing findings and interventions.
Trauma surgeons must document the extent of injury and repairs performed.
S31.61 indicates a laceration that penetrates the peritoneal cavity, while S31.60 refers to a laceration without penetration. The presence of penetration significantly increases the complexity and potential complications associated with the injury.
