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ICD-10 Guide
ICD-10 CodesS31.821

S31.821

Billable

Laceration without foreign body of left buttock

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

Code Description

ICD-10 S31.821 is a billable code used to indicate a diagnosis of laceration without foreign body of left buttock.

Key Diagnostic Point:

S31.821 refers to a laceration of the left buttock that does not involve any foreign body. This type of injury is often the result of blunt trauma, falls, or accidents, and can vary in severity from superficial cuts to deeper wounds that may involve underlying tissues such as muscle or fascia. The buttock region is particularly vulnerable due to its exposure in certain activities and its anatomical position. Clinically, such lacerations may present with pain, swelling, and potential bleeding. Assessment typically involves a thorough physical examination to determine the depth and extent of the injury, as well as any associated injuries to the pelvic region or lumbar spine. In cases where the laceration is extensive, emergency surgical intervention may be required to repair the tissue and prevent complications such as infection or significant blood loss. Proper documentation of the injury's characteristics, including size, depth, and any associated trauma, is essential for accurate coding and treatment planning.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in injury severity and depth
  • Potential for associated injuries in the pelvic region
  • Need for detailed documentation of the laceration characteristics
  • Differentiation from similar codes for lacerations in other locations

Audit Risk Factors

  • Inadequate documentation of injury specifics
  • Failure to note associated injuries
  • Misclassification of laceration depth
  • Inconsistent coding of emergency interventions

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 trauma from falls, accidents, or sports injuries resulting in buttock lacerations.

Billing Considerations

Ensure that all associated injuries are documented to support the complexity of the case.

Orthopedic Surgery

Documentation Requirements

Comprehensive assessment of the laceration and any potential involvement of underlying structures.

Common Clinical Scenarios

Surgical repair of deep lacerations that may involve muscle or fascia.

Billing Considerations

Documentation should include details on the surgical approach and any complications encountered.

Coding Guidelines

Inclusion Criteria

Use S31.821 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the injury's specifics
  • Include details on the mechanism of injury and any associated conditions

Exclusion Criteria

Do NOT use S31.821 When
  • Exclude codes for lacerations with foreign bodies or those that are not specific to the left buttock

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used for suturing a laceration on the left buttock.

Documentation Requirements

Document the size and depth of the laceration, as well as the repair technique used.

Specialty Considerations

Orthopedic surgeons should note any involvement of deeper structures.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of lacerations, improving the accuracy of data collection and reimbursement processes. S31.821 provides a clear distinction for lacerations without foreign bodies, which aids in clinical management and research.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of lacerations, improving the accuracy of data collection and reimbursement processes. S31.821 provides a clear distinction for lacerations without foreign bodies, which aids in clinical management and research.

Reimbursement & Billing Impact

reimbursement processes. S31.821 provides a clear distinction for lacerations without foreign bodies, which aids in clinical management and research.

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 S31.821 accurately?

Accurate coding of S31.821 is crucial for proper treatment planning, reimbursement, and data analysis. It ensures that healthcare providers can track injury patterns and outcomes effectively.