Laceration without foreign body of pharynx and cervical esophagus
ICD-10 S11.21 is a billable code used to indicate a diagnosis of laceration without foreign body of pharynx and cervical esophagus.
S11.21 refers to a laceration of the pharynx and cervical esophagus that occurs without the presence of a foreign body. This type of injury can result from various mechanisms, including blunt trauma, penetrating injuries, or accidental ingestion of sharp objects. Clinical presentation may include pain, difficulty swallowing (dysphagia), and potential airway compromise. Diagnosis typically involves a thorough history and physical examination, often supplemented by imaging studies such as CT scans or endoscopy to assess the extent of the injury. Management may require surgical intervention, especially if there is significant tissue damage or risk of perforation. Complications can include infection, abscess formation, and stricture development. Accurate coding is essential for proper reimbursement and tracking of injury patterns in clinical practice.
Documentation must include a detailed account of the injury mechanism, patient symptoms, and initial assessment findings.
Trauma cases involving falls, assaults, or accidents leading to lacerations of the throat.
Emergency providers should ensure that all relevant details are captured to support the diagnosis and any potential surgical interventions.
Operative reports must detail the surgical approach, findings, and any repairs performed.
Surgical management of lacerations requiring repair or reconstruction due to significant tissue loss.
Surgeons should document the extent of the injury and any complications encountered during the procedure.
Used to evaluate the extent of injury in cases of suspected esophageal laceration.
Document findings from the esophagoscopy, including any interventions performed.
Ensure that the procedure is linked to the diagnosis of laceration for accurate billing.
S11.21 is used for lacerations without foreign bodies, while S11.22 is for lacerations that involve foreign bodies. Accurate documentation is crucial to determine which code to use.
