Puncture wound without foreign body of abdominal wall, periumbilic region with penetration into peritoneal cavity
ICD-10 S31.635 is a billable code used to indicate a diagnosis of puncture wound without foreign body of abdominal wall, periumbilic region with penetration into peritoneal cavity.
S31.635 describes a puncture wound located in the periumbilical region of the abdominal wall that has penetrated into the peritoneal cavity without the presence of a foreign body. This type of injury is often the result of blunt or penetrating trauma, such as a stab wound or an accidental puncture from a sharp object. The peritoneal cavity houses vital organs, and penetration can lead to serious complications, including peritonitis, hemorrhage, and organ damage. Clinical evaluation typically involves a thorough physical examination, imaging studies such as ultrasound or CT scans, and possibly exploratory surgery to assess the extent of the injury. Management may require emergency surgical intervention to repair any damage and prevent infection. The absence of a foreign body is significant, as it influences the treatment approach and potential complications. Accurate coding is essential for proper billing and to reflect the severity of the injury in the patient's medical record.
Detailed documentation of the mechanism of injury, physical examination findings, and any imaging results.
Patients presenting with stab wounds, accidental punctures, or trauma from falls.
Ensure that all relevant details about the injury and treatment are captured to support the coding.
Operative reports must clearly describe the findings during surgery, including any repairs made to the peritoneal cavity.
Exploratory laparotomy for suspected abdominal injuries following trauma.
Accurate coding of any additional procedures performed during surgery is crucial.
Used when surgical intervention is required to assess and repair abdominal injuries.
Operative report detailing findings and procedures performed.
General surgeons must ensure accurate coding of all procedures performed during surgery.
Accurate coding of S31.635 is crucial for proper reimbursement, tracking of trauma cases, and ensuring that the severity of the patient's condition is reflected in their medical record. It also aids in the management of potential complications arising from the injury.
