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ICD-10 Guide
ICD-10 CodesS31.801

S31.801

Billable

Laceration without foreign body of unspecified buttock

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

Code Description

ICD-10 S31.801 is a billable code used to indicate a diagnosis of laceration without foreign body of unspecified buttock.

Key Diagnostic Point:

A laceration of the buttock is a common injury that can occur due to various mechanisms such as falls, accidents, or blunt trauma. This specific code, S31.801, is used when a laceration occurs without the presence of a foreign body, indicating that the injury is a clean cut or tear of the skin and underlying tissues. The buttock region is anatomically complex, containing muscles, nerves, and blood vessels, which can be affected by such injuries. The severity of the laceration can vary from superficial cuts to deep wounds that may involve muscle or fat tissue. Proper assessment is crucial to determine the extent of the injury and the need for surgical intervention. In cases where the laceration is deep or extensive, emergency surgical procedures may be required to repair the tissue, control bleeding, and prevent infection. Documentation should include the mechanism of injury, the depth of the laceration, and any associated injuries to ensure accurate coding and appropriate treatment.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation of injury severity
  • Potential for associated injuries in the pelvic region
  • Need for differentiation from other types of lacerations
  • Variability in treatment approaches based on injury depth

Audit Risk Factors

  • Inadequate documentation of injury mechanism
  • Failure to document associated injuries
  • Misclassification of laceration depth
  • Inconsistent coding of follow-up treatments

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Detailed description of the injury, mechanism of injury, and any immediate interventions performed.

Common Clinical Scenarios

Patients presenting with lacerations from falls, accidents, or sports injuries.

Billing Considerations

Ensure that the depth and extent of the laceration are clearly documented to guide treatment and coding.

Orthopedic Surgery

Documentation Requirements

Comprehensive assessment of the injury, including imaging results if applicable.

Common Clinical Scenarios

Patients with lacerations that may involve underlying muscle or require surgical repair.

Billing Considerations

Document any associated fractures or soft tissue injuries that may complicate the laceration.

Coding Guidelines

Inclusion Criteria

Use S31.801 When
  • According to ICD
  • 10 coding guidelines, this code should be used when a laceration is documented without a foreign body
  • It is important to ensure that the documentation specifies the location and depth of the laceration

Exclusion Criteria

Do NOT use S31.801 When
  • Exclusions include lacerations with foreign bodies or those that are part of a more complex injury requiring different coding

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used for lacerations requiring simple closure without complications.

Documentation Requirements

Document the size of the laceration and the method of closure.

Specialty Considerations

Emergency medicine and surgical specialties should ensure accurate documentation of the procedure 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 lacerations. This specificity helps in better tracking of injury types and outcomes, leading to improved patient care and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including lacerations. This specificity helps in better tracking of injury types and outcomes, leading to improved patient care and resource allocation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of injuries, including lacerations. This specificity helps in better tracking of injury types and outcomes, leading to improved patient care and resource allocation.

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 should I document to support the use of code S31.801?

Document the mechanism of injury, the depth of the laceration, any associated injuries, and the treatment provided. Clear documentation will support the accuracy of coding and billing.