Open wound of anus
ICD-10 S31.83 is a billable code used to indicate a diagnosis of open wound of anus.
An open wound of the anus refers to a laceration or tear in the anal region, which can occur due to various traumatic events such as accidents, falls, or penetrating injuries. This type of injury may be associated with significant pain, bleeding, and potential complications such as infection or fecal incontinence. The severity of the wound can vary from superficial abrasions to deep lacerations that may involve the anal sphincter or surrounding tissues. In cases of abdominal trauma, pelvic injuries, or lumbar spine trauma, the presence of an open wound of the anus may indicate a more extensive injury pattern, necessitating thorough evaluation and management. Emergency surgical interventions may be required to repair the wound, control bleeding, and prevent infection. Proper assessment and documentation of the injury's extent, associated injuries, and the patient's overall condition are crucial for accurate coding and treatment planning.
Detailed account of the injury mechanism, patient assessment, and treatment provided.
Trauma cases involving falls, motor vehicle accidents, or penetrating injuries.
Timely documentation is critical for accurate coding and billing, especially in emergency settings.
Operative reports detailing the surgical procedure, extent of the wound, and any complications.
Surgical repair of anal lacerations or wounds following trauma.
Documentation must clearly outline the surgical approach and any additional procedures performed.
Used when an abscess develops from an open wound of the anus.
Operative report detailing the procedure and indication.
General surgery documentation must include the extent of the wound and any complications.
The primary documentation needed includes a detailed description of the injury, the mechanism of injury, any associated injuries, and the treatment provided, especially if surgical intervention is performed.
