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ICD-10 Guide
ICD-10 CodesS21.02

S21.02

Billable

Laceration with foreign body of breast

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/23/2025

Code Description

ICD-10 S21.02 is a billable code used to indicate a diagnosis of laceration with foreign body of breast.

Key Diagnostic Point:

S21.02 refers to a laceration of the breast that is complicated by the presence of a foreign body. This condition typically arises from traumatic incidents such as accidents, falls, or penetrating injuries. The foreign body may include items like glass, metal, or other debris that can cause additional tissue damage and complicate the healing process. Clinically, the presence of a foreign body can lead to increased risk of infection, delayed healing, and may necessitate surgical intervention for removal. The management of such injuries often requires a multidisciplinary approach, involving trauma surgeons, plastic surgeons, and wound care specialists to ensure optimal recovery and cosmetic outcomes. Accurate coding of this condition is crucial for appropriate treatment planning and reimbursement, as it reflects the complexity of the injury and the potential need for advanced surgical techniques or follow-up care.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Presence of foreign body complicates the injury.
  • Potential for associated injuries (e.g., pneumothorax, hemothorax).
  • Need for detailed documentation of the injury mechanism.
  • Variability in treatment approaches based on foreign body type.

Audit Risk Factors

  • Inadequate documentation of the foreign body type.
  • Failure to document associated injuries.
  • Misclassification of the injury severity.
  • Lack of clarity on the mechanism of injury.

Specialty Focus

Medical Specialties

Trauma Surgery

Documentation Requirements

Detailed descriptions of the injury mechanism, foreign body characteristics, and any surgical interventions performed.

Common Clinical Scenarios

Management of traumatic breast injuries with foreign bodies, including surgical repair and foreign body removal.

Billing Considerations

Documentation must clearly indicate the need for surgical intervention and any complications arising from the foreign body.

Plastic Surgery

Documentation Requirements

Comprehensive notes on cosmetic considerations, reconstruction plans, and follow-up care.

Common Clinical Scenarios

Reconstructive procedures following traumatic lacerations with foreign bodies.

Billing Considerations

Attention to aesthetic outcomes and potential complications from foreign body presence.

Coding Guidelines

Inclusion Criteria

Use S21.02 When
  • According to ICD
  • 10 guidelines, S21
  • 02 should be used when a laceration of the breast is accompanied by a foreign body
  • Coders must ensure that documentation supports the presence of the foreign body and any associated injuries

Exclusion Criteria

Do NOT use S21.02 When
  • Exclusion criteria include lacerations without foreign bodies or those classified under different injury codes

Related ICD-10 Codes

Related CPT Codes

19316CPT Code

Mastectomy, partial

Clinical Scenario

Used when surgical intervention is required for extensive lacerations with foreign bodies.

Documentation Requirements

Operative report detailing the procedure and rationale for mastectomy.

Specialty Considerations

Plastic surgeons may need to document aesthetic considerations post-surgery.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of injuries, including those with foreign bodies. S21.02 provides a clear distinction from other laceration codes, facilitating better tracking of treatment outcomes and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including those with foreign bodies. S21.02 provides a clear distinction from other laceration codes, facilitating better tracking of treatment outcomes and resource allocation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of injuries, including those with foreign bodies. S21.02 provides a clear distinction from other laceration codes, facilitating better tracking of treatment outcomes and resource allocation.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What is the importance of documenting the foreign body type?

Documenting the foreign body type is crucial for accurate coding, as it affects treatment decisions and potential complications. It also supports the complexity of the injury, which is essential for reimbursement.