Open wound of trachea
ICD-10 S11.02 is a billable code used to indicate a diagnosis of open wound of trachea.
An open wound of the trachea is a serious injury that involves a breach in the integrity of the tracheal wall, which can result from penetrating trauma, such as stab wounds or gunshot injuries, or from blunt trauma that causes laceration. This type of injury can lead to significant airway compromise, respiratory distress, and potential aspiration of foreign materials. The trachea, being a vital structure in the respiratory system, is susceptible to damage from external forces, and such injuries often require immediate medical intervention. Clinical presentation may include difficulty breathing, stridor, subcutaneous emphysema, and visible wounds on the neck. Diagnosis typically involves a thorough physical examination, imaging studies such as CT scans, and possibly bronchoscopy to assess the extent of the injury. Management may include securing the airway, surgical repair, and monitoring for complications such as infection or tracheal stenosis. Given the critical nature of this injury, timely and accurate coding is essential for appropriate treatment and reimbursement.
Documentation must include details of the mechanism of injury, initial assessment findings, and any immediate interventions performed.
Trauma cases involving stabbings or gunshot wounds to the neck, as well as accidental injuries from foreign objects.
Ensure that all relevant details are captured in the emergency department notes to support the coding of the injury.
Operative reports should detail the surgical approach, repair techniques used, and any complications encountered during the procedure.
Surgical repair of tracheal lacerations or reconstruction following trauma.
Accurate coding requires clear documentation of the surgical procedure and any associated codes for additional interventions.
Used in cases of airway compromise due to tracheal injury.
Document the indication for intubation and any complications.
Emergency medicine providers must ensure clear documentation of the airway management process.
S11.02 is used for open wounds of the trachea, while S11.01 is for closed wounds. Accurate documentation of the injury type is essential for correct coding.
