Puncture wound with foreign body of left breast
ICD-10 S21.042 is a billable code used to indicate a diagnosis of puncture wound with foreign body of left breast.
A puncture wound with a foreign body in the left breast typically occurs due to trauma, such as a stab wound or an injury from a sharp object. This type of injury can lead to various complications, including infection, bleeding, and damage to underlying structures such as muscles, nerves, and blood vessels. The presence of a foreign body can complicate the healing process and may require surgical intervention for removal. Clinicians must assess the extent of the injury, including any associated chest trauma, rib fractures, pneumothorax, or hemothorax, which can occur due to penetrating injuries in the thoracic region. Cardiac injuries may also be a concern if the wound is deep enough to affect the pericardium or myocardium. Proper imaging and evaluation are crucial to determine the need for thoracic surgical interventions, such as chest tube placement or exploratory surgery, to address any complications arising from the injury.
Detailed description of the mechanism of injury, assessment of associated injuries, and treatment provided.
Patients presenting with stab wounds, gunshot wounds, or accidental punctures.
Ensure that all associated injuries are documented to support coding for potential complications.
Operative reports detailing the removal of foreign bodies and any repairs made to underlying structures.
Surgical intervention for foreign body removal and repair of damaged tissues.
Documentation must specify the type of foreign body and any complications encountered during surgery.
Used when an abscess forms due to the puncture wound.
Document the size, location, and nature of the abscess.
Ensure that the procedure is linked to the diagnosis of the puncture wound.
Documentation should include the mechanism of injury, the type and location of the foreign body, any associated injuries, and the treatment provided.
