Puncture wound without foreign body of abdominal wall, right upper quadrant with penetration into peritoneal cavity
ICD-10 S31.630 is a billable code used to indicate a diagnosis of puncture wound without foreign body of abdominal wall, right upper quadrant with penetration into peritoneal cavity.
A puncture wound of the abdominal wall in the right upper quadrant that penetrates the peritoneal cavity is a serious injury that can lead to significant complications. This type of wound typically occurs due to trauma, such as a stab wound or a gunshot wound, and can result in damage to internal organs, including the liver, gallbladder, and portions of the small intestine. The peritoneal cavity is a potential space that can become contaminated with bacteria, leading to peritonitis, a life-threatening condition. Immediate assessment and intervention are crucial, as the patient may present with abdominal pain, tenderness, and signs of internal bleeding. Surgical intervention is often required to repair any damaged organs and to clean the peritoneal cavity to prevent infection. The management of such injuries involves a multidisciplinary approach, including trauma surgeons, emergency medicine physicians, and critical care specialists.
Detailed operative reports, including descriptions of the injury, surgical procedures performed, and any complications.
Management of stab wounds, gunshot wounds, and other penetrating abdominal injuries.
Ensure accurate coding of any additional procedures performed during surgery.
Thorough documentation of initial assessment, imaging studies, and treatment provided in the emergency department.
Initial evaluation and stabilization of patients with abdominal trauma.
Document vital signs and any interventions performed prior to surgical consultation.
Used when surgical intervention is required for penetrating abdominal injuries.
Operative report detailing findings and procedures performed.
Trauma surgeons should ensure accurate coding of all procedures performed during surgery.
S31.630 is used for puncture wounds without a foreign body, while S31.631 is for those with a foreign body present. Accurate documentation is essential to determine which code to use.
