Open wound of right buttock
ICD-10 S31.81 is a billable code used to indicate a diagnosis of open wound of right buttock.
An open wound of the right buttock refers to a laceration or puncture that penetrates the skin and underlying tissues in the right gluteal region. This type of injury can result from various mechanisms, including trauma from falls, accidents, or penetrating injuries such as knife wounds or gunshot wounds. The buttock area is rich in muscle and vascular structures, making it susceptible to complications such as infection, hematoma formation, and damage to underlying structures, including nerves and blood vessels. In cases of significant trauma, associated injuries may involve the pelvic region, lumbar spine, or genitourinary system, necessitating a comprehensive evaluation. Emergency surgical interventions may be required to manage the wound, control bleeding, and prevent infection. Proper assessment and documentation of the wound's size, depth, and any foreign bodies present are crucial for accurate coding and treatment planning. The management of such wounds often involves wound care, possible surgical debridement, and monitoring for complications.
Detailed description of the injury mechanism, wound assessment, and any interventions performed.
Trauma patients presenting with open wounds from accidents, falls, or assaults.
Ensure thorough documentation of vital signs and any immediate interventions to support coding.
Operative notes detailing the extent of the wound, surgical procedures performed, and postoperative care.
Patients requiring surgical intervention for wound debridement or repair.
Accurate coding of surgical procedures performed in conjunction with the wound care.
Used for suturing an open wound on the right buttock.
Document the size of the wound and the method of repair.
Ensure that the procedure is linked to the correct diagnosis code.
S31.81 is used for open wounds of the right buttock, while S31.80 is for closed wounds. Accurate documentation of the wound type is essential for correct coding.
