Puncture wound without foreign body of abdominal wall, right lower quadrant with penetration into peritoneal cavity
ICD-10 S31.633 is a billable code used to indicate a diagnosis of puncture wound without foreign body of abdominal wall, right lower quadrant with penetration into peritoneal cavity.
A puncture wound of the abdominal wall in the right lower quadrant that penetrates the peritoneal cavity is a significant injury often resulting from trauma such as stab wounds, gunshot wounds, or accidental injuries. This type of wound can lead to serious complications, including peritonitis, internal bleeding, and damage to abdominal organs such as the intestines, bladder, or reproductive organs. The right lower quadrant is particularly concerning due to the proximity of the appendix and the right ovary in females, which may also be affected. Immediate assessment and intervention are critical, as the presence of a penetrating wound necessitates surgical evaluation to determine the extent of internal injury and to prevent further complications. Emergency surgical interventions may include exploratory laparotomy, repair of any damaged organs, and management of any hemorrhage. Proper documentation of the mechanism of injury, the extent of the wound, and any surgical procedures performed is essential for accurate coding and billing.
Detailed account of the injury mechanism, vital signs, and initial assessment findings.
Patients presenting with stab wounds, gunshot wounds, or accidental punctures to the abdomen.
Timely documentation is crucial due to the acute nature of the injuries.
Operative reports detailing the surgical approach, findings, and any repairs made.
Exploratory laparotomy for penetrating abdominal injuries.
Accurate coding of any additional procedures performed during surgery.
Used when a patient with a puncture wound requires surgical exploration.
Operative report detailing findings and procedures performed.
General surgeons must document the extent of the injury and any repairs made.
Coding S31.633 accurately reflects the severity of the injury and the need for potential surgical intervention, which is crucial for appropriate treatment and reimbursement.
