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ICD-10 Guide
ICD-10 CodesS21.132

S21.132

Billable

Puncture wound without foreign body of left front wall of thorax without penetration into thoracic cavity

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

Code Description

ICD-10 S21.132 is a billable code used to indicate a diagnosis of puncture wound without foreign body of left front wall of thorax without penetration into thoracic cavity.

Key Diagnostic Point:

A puncture wound of the left front wall of the thorax refers to a penetrating injury that does not involve a foreign body and does not breach the thoracic cavity. This type of injury can occur due to various mechanisms, including sharp objects or projectiles. Clinically, it is essential to assess the extent of the injury, as it may lead to complications such as pneumothorax (air in the pleural space), hemothorax (blood in the pleural space), or rib fractures. While the wound itself may not penetrate the thoracic cavity, the potential for underlying injuries necessitates thorough evaluation. Patients may present with localized pain, swelling, and tenderness over the affected area. Diagnostic imaging, such as chest X-rays or CT scans, may be required to rule out associated injuries. Treatment typically involves wound care, pain management, and monitoring for complications. In some cases, surgical intervention may be necessary if there are significant injuries to the underlying structures, such as the lungs or major blood vessels.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between types of thoracic injuries
  • Assessing for associated rib fractures or pneumothorax
  • Understanding the implications of non-penetrating versus penetrating injuries
  • Documentation of the mechanism of injury

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to document associated injuries
  • Misclassification of the wound type
  • Lack of follow-up documentation for complications

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Detailed account of the injury mechanism, physical examination findings, and any imaging results.

Common Clinical Scenarios

Patients presenting with stab wounds, gunshot wounds, or accidental punctures.

Billing Considerations

Ensure that all associated injuries are documented to avoid undercoding.

Trauma Surgery

Documentation Requirements

Comprehensive surgical notes detailing the procedure, findings, and any interventions performed.

Common Clinical Scenarios

Surgical intervention for thoracic injuries, including repair of lung lacerations or drainage of hemothorax.

Billing Considerations

Accurate coding of any surgical procedures performed in conjunction with the wound care.

Coding Guidelines

Inclusion Criteria

Use S21.132 When
  • According to ICD
  • 10 guidelines, S21
  • 132 should be used when documenting a puncture wound without foreign body that does not penetrate the thoracic cavity
  • Coders must ensure that the documentation supports the diagnosis and that any associated injuries are coded appropriately

Exclusion Criteria

Do NOT use S21.132 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

99283CPT Code

Emergency department visit, moderate severity

Clinical Scenario

Used for initial evaluation of a patient with a puncture wound.

Documentation Requirements

Document the history, examination findings, and any imaging performed.

Specialty Considerations

Emergency medicine providers should ensure that all relevant details are captured.

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 puncture wounds. This specificity aids in better tracking of injury types and associated complications, improving patient care and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including puncture wounds. This specificity aids in better tracking of injury types and associated complications, improving patient care and resource allocation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of injuries, including puncture wounds. This specificity aids in better tracking of injury types and associated complications, improving patient care 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 difference between a puncture wound and a laceration?

A puncture wound is a deep wound caused by a sharp object that penetrates the skin, while a laceration is a tear or cut in the skin that may be jagged or irregular.