Laceration with foreign body, right lower leg
ICD-10 S81.821 is a billable code used to indicate a diagnosis of laceration with foreign body, right lower leg.
S81.821 refers to a laceration in the right lower leg that is complicated by the presence of a foreign body. This condition typically arises from traumatic injuries such as falls, accidents, or sports-related incidents. The right lower leg encompasses the area from the knee to the ankle, including the tibia and fibula. The presence of a foreign body, such as glass, metal, or wood, can complicate the injury, leading to increased risk of infection, delayed healing, and potential for further surgical intervention. Treatment often involves thorough cleaning of the wound, removal of the foreign body, and possibly suturing the laceration. In cases where the foreign body has penetrated deeply, imaging studies may be required to assess the extent of the injury and to ensure complete removal. The management of such injuries is critical to prevent complications and ensure optimal recovery, especially in active individuals or athletes. Proper documentation of the injury mechanism, foreign body type, and treatment provided is essential for accurate coding and billing.
Detailed operative notes, imaging results, and follow-up care documentation.
Surgical removal of foreign bodies, repair of lacerations, management of fractures associated with lacerations.
Ensure that all surgical interventions are documented, including the type of foreign body and any complications encountered.
Comprehensive documentation of initial assessment, treatment provided, and any referrals made.
Initial evaluation and management of traumatic lacerations with foreign bodies.
Accurate documentation of the mechanism of injury and immediate care provided is crucial for coding.
Used when a simple laceration repair is performed in conjunction with foreign body removal.
Document the size of the laceration and the foreign body type.
Orthopedic surgeons should ensure that all aspects of the procedure are documented.
Documenting the foreign body type is crucial for accurate coding and treatment planning. It helps in assessing the risk of infection and determining the appropriate management strategy.
