Puncture wound with foreign body of right eyelid and periocular area
ICD-10 S01.141 is a billable code used to indicate a diagnosis of puncture wound with foreign body of right eyelid and periocular area.
A puncture wound with a foreign body in the right eyelid and periocular area typically occurs due to sharp objects penetrating the skin, which can include items like metal shards, glass, or wood. This type of injury can lead to significant complications, including infection, damage to the eyelid structures, and potential injury to the underlying ocular structures. The clinical presentation may include localized pain, swelling, and redness around the wound site, along with the presence of a visible foreign body. Diagnosis involves a thorough clinical examination, often supplemented by imaging studies such as X-rays or CT scans to assess for deeper penetration and to locate the foreign body. Management typically includes careful removal of the foreign body, wound cleaning, and possibly suturing if the wound is extensive. Antibiotic prophylaxis may be indicated to prevent infection, especially if the foreign body is contaminated. Follow-up care is essential to monitor for complications such as infection or delayed healing.
Documentation must include a detailed account of the injury mechanism, foreign body characteristics, and immediate treatment provided.
Patients presenting with puncture wounds from accidents, fights, or sports injuries.
Ensure that all relevant details about the injury and treatment are captured to support the coding.
Operative reports should detail the procedure for foreign body removal, including any complications encountered.
Surgical intervention for deep puncture wounds with foreign bodies requiring exploration.
Document any additional procedures performed, such as repair of eyelid structures.
Used when a foreign body is removed from the eyelid during a procedure.
Operative report detailing the procedure and any complications.
Ensure that the procedure is documented in the context of the injury.
Documenting the foreign body type is crucial for accurate coding, as it impacts treatment decisions and potential complications.
