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ICD-10 Guide
ICD-10 CodesS31.641

S31.641

Billable

Puncture wound with foreign body of abdominal wall, left upper quadrant with penetration into peritoneal cavity

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/23/2025

Code Description

ICD-10 S31.641 is a billable code used to indicate a diagnosis of puncture wound with foreign body of abdominal wall, left upper quadrant with penetration into peritoneal cavity.

Key Diagnostic Point:

S31.641 describes a puncture wound located in the left upper quadrant of the abdominal wall that has penetrated into the peritoneal cavity and involves a foreign body. This type of injury is often the result of trauma, such as a stab wound or an accidental puncture from a sharp object. The presence of a foreign body complicates the clinical picture, as it may lead to infection, peritonitis, or other serious complications. Clinicians must assess the extent of the injury, including any damage to underlying organs such as the spleen, stomach, or diaphragm. Emergency surgical intervention is typically required to remove the foreign body, repair any damaged structures, and prevent further complications. The management of such injuries requires a multidisciplinary approach, involving trauma surgeons, emergency medicine physicians, and radiologists for imaging studies to evaluate the extent of the injury and guide treatment decisions.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Presence of foreign body complicates the clinical picture.
  • Potential for associated organ injuries requires thorough documentation.
  • Need for emergency surgical intervention increases coding complexity.
  • Variability in clinical presentation can lead to misclassification.

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury.
  • Failure to specify the presence of a foreign body.
  • Lack of detail regarding surgical interventions performed.
  • Misclassification of the injury type or location.

Specialty Focus

Medical Specialties

Trauma Surgery

Documentation Requirements

Detailed operative reports and imaging studies must be included.

Common Clinical Scenarios

Management of stab wounds, gunshot wounds, or accidental punctures.

Billing Considerations

Documentation must specify the type of foreign body and any associated injuries.

Emergency Medicine

Documentation Requirements

Initial assessment notes, imaging results, and treatment plans are crucial.

Common Clinical Scenarios

Patients presenting with acute abdominal pain following trauma.

Billing Considerations

Timely documentation is essential for accurate coding and billing.

Coding Guidelines

Inclusion Criteria

Use S31.641 When
  • According to ICD
  • CM guidelines, S31
  • 641 should be used when there is a documented puncture wound with a foreign body that has penetrated the peritoneal cavity
  • Coders must ensure that the documentation supports the diagnosis and includes details about the foreign body and any surgical procedures performed

Exclusion Criteria

Do NOT use S31.641 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

49000CPT Code

Exploratory laparotomy

Clinical Scenario

Used when a patient with a puncture wound requires surgical exploration.

Documentation Requirements

Operative report detailing findings and interventions.

Specialty Considerations

Trauma surgeons must document the extent of injury and any repairs performed.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of injuries, including those with foreign bodies. This specificity aids in better tracking of trauma cases and improves the accuracy of healthcare data.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including those with foreign bodies. This specificity aids in better tracking of trauma cases and improves the accuracy of healthcare data.

Reimbursement & Billing Impact

reimbursement and compliance.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What is the significance of coding S31.641 accurately?

Accurate coding of S31.641 is crucial for proper reimbursement, tracking of trauma cases, and ensuring that patients receive appropriate care based on the severity of their injuries.