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ICD-10 Guide
ICD-10 CodesS31.645

S31.645

Billable

Puncture wound with foreign body of abdominal wall, periumbilic region with penetration into peritoneal cavity

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

Code Description

ICD-10 S31.645 is a billable code used to indicate a diagnosis of puncture wound with foreign body of abdominal wall, periumbilic region with penetration into peritoneal cavity.

Key Diagnostic Point:

S31.645 describes a puncture wound located in the periumbilical region 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 peritoneal cavity is a potential space within the abdomen that houses various organs, and penetration into this area can lead to serious complications, including peritonitis, hemorrhage, and organ damage. Immediate medical evaluation is crucial to assess the extent of the injury, determine the presence of any foreign bodies, and initiate appropriate surgical intervention if necessary. The management of such injuries typically involves imaging studies, such as ultrasound or CT scans, to evaluate the internal structures and guide treatment decisions. Surgical intervention may be required to remove the foreign body, repair any damaged organs, and prevent infection.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Requires detailed documentation of the mechanism of injury.
  • Involves assessment of potential complications such as organ damage.
  • May necessitate surgical intervention with specific procedural coding.
  • Requires knowledge of anatomy and the implications of peritoneal penetration.

Audit Risk Factors

  • Inadequate documentation of the foreign body type and location.
  • Failure to document the mechanism of injury.
  • Lack of imaging or surgical reports to support the diagnosis.
  • Inconsistent coding of related procedures.

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Detailed account of the injury mechanism, imaging results, and treatment provided.

Common Clinical Scenarios

Patients presenting with stab wounds, gunshot wounds, or accidental punctures.

Billing Considerations

Timely documentation is critical due to the potential for rapid deterioration.

General Surgery

Documentation Requirements

Operative reports detailing the surgical approach, findings, and any foreign body removal.

Common Clinical Scenarios

Surgical intervention for abdominal trauma with foreign body retrieval.

Billing Considerations

Accurate coding of surgical procedures performed in conjunction with the injury.

Coding Guidelines

Inclusion Criteria

Use S31.645 When
  • According to ICD
  • 10 coding guidelines, S31
  • 645 should be used when there is clear documentation of a puncture wound with a foreign body that has penetrated the peritoneal cavity
  • Coders must ensure that the documentation supports the diagnosis and that any related procedures are accurately coded

Exclusion Criteria

Do NOT use S31.645 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

49002CPT Code

Exploratory laparotomy, diagnostic

Clinical Scenario

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

Documentation Requirements

Operative report detailing findings and interventions.

Specialty Considerations

General surgeons must document the extent of the 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, such as S31.645, which provides greater detail on the nature of the injury and its implications for treatment and reimbursement.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, such as S31.645, which provides greater detail on the nature of the injury and its implications for treatment and reimbursement.

Reimbursement & Billing Impact

reimbursement.

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 S31.645 accurately?

Accurate coding of S31.645 is crucial for proper reimbursement, as it reflects the severity of the injury and the complexity of care required. It also aids in tracking injury patterns and outcomes for quality improvement.