Open wound of unspecified buttock
ICD-10 S31.80 is a billable code used to indicate a diagnosis of open wound of unspecified buttock.
An open wound of the buttock is characterized by a break in the skin and underlying tissues in the gluteal region, which may result from trauma, surgical procedures, or other injuries. This type of wound can vary in severity, ranging from superficial abrasions to deep lacerations that may involve muscles, nerves, and blood vessels. The buttock area is prone to various types of trauma, including blunt force injuries from falls or accidents, penetrating injuries from sharp objects, and surgical wounds from procedures involving the pelvic region. The management of open wounds in this area requires careful assessment to determine the extent of tissue damage, potential for infection, and the need for surgical intervention. Emergency surgical interventions may be necessary to control bleeding, debride necrotic tissue, or repair damaged structures. Additionally, the presence of associated injuries, such as pelvic fractures or lumbar spine trauma, may complicate the clinical picture and necessitate a multidisciplinary approach to treatment. Proper coding of this condition is essential for accurate billing and to ensure appropriate care is provided.
Detailed description of the mechanism of injury, wound assessment, and any interventions performed.
Trauma cases involving falls, motor vehicle accidents, or assaults resulting in buttock injuries.
Ensure that all associated injuries are documented to support comprehensive coding.
Operative reports detailing the extent of the wound, surgical interventions, and post-operative care.
Surgical repair of traumatic wounds or abscess drainage in the buttock region.
Accurate coding of surgical procedures performed in conjunction with the wound care.
Used for repair of an open wound on the buttock after assessment.
Document the size, depth, and location of the wound.
Ensure that the procedure is documented as a simple repair versus more complex interventions.
Use S31.80 when the documentation does not specify the exact location of the wound on the buttock or when the wound is not classified as left or right. Always ensure that the use of unspecified codes is justified by the clinical documentation.
