Puncture wound without foreign body of abdominal wall with penetration into peritoneal cavity
ICD-10 S31.63 is a billable code used to indicate a diagnosis of puncture wound without foreign body of abdominal wall with penetration into peritoneal cavity.
A puncture wound of the abdominal wall that penetrates the peritoneal cavity is a significant injury that can lead to serious complications, including peritonitis and organ damage. This type of injury typically occurs due to trauma, such as stab wounds, gunshot wounds, or accidental punctures from sharp objects. The absence of a foreign body indicates that the wound is not complicated by retained materials, which can simplify the management of the injury. Clinically, patients may present with abdominal pain, tenderness, and signs of peritoneal irritation. Emergency evaluation often includes imaging studies to assess for internal injuries and bleeding. Surgical intervention may be necessary to repair any damaged organs or to clean the peritoneal cavity. The management of such injuries requires a multidisciplinary approach, often involving trauma surgeons, radiologists, and emergency medicine specialists. Proper coding is essential for accurate billing and to reflect the severity of the injury in the patient's medical record.
Detailed operative notes describing the injury, surgical interventions, and any complications.
Management of stab wounds, gunshot wounds, and accidental punctures.
Accurate coding requires thorough documentation of the surgical findings and any repairs performed.
Comprehensive assessment notes including vital signs, imaging results, and initial management steps.
Initial evaluation and stabilization of trauma patients with abdominal injuries.
Timely documentation is crucial for accurate coding and billing, especially in acute settings.
Used when surgical intervention is required for abdominal puncture wounds.
Operative report detailing findings and procedures performed.
Trauma surgeons must document the extent of injury and any repairs made.
Accurate coding of S31.63 is crucial for proper reimbursement, tracking of trauma cases, and ensuring that patients receive appropriate care based on the severity of their injuries.
