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ICD-10 Guide
ICD-10 CodesS21.221

S21.221

Billable

Laceration with foreign body of right back wall of thorax without penetration into thoracic cavity

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

Code Description

ICD-10 S21.221 is a billable code used to indicate a diagnosis of laceration with foreign body of right back wall of thorax without penetration into thoracic cavity.

Key Diagnostic Point:

S21.221 refers to a specific type of chest trauma characterized by a laceration on the right back wall of the thorax that involves a foreign body but does not penetrate the thoracic cavity. This condition can arise from various incidents, including accidents, falls, or penetrating injuries from sharp objects. The presence of a foreign body can complicate the injury, as it may lead to infection, inflammation, or further tissue damage. Clinically, patients may present with localized pain, swelling, and potential signs of infection. It is crucial to assess for associated injuries such as rib fractures, pneumothorax, or hemothorax, which can occur in conjunction with thoracic wall injuries. Proper imaging and evaluation are necessary to rule out deeper injuries to the lungs or heart. Treatment typically involves wound care, possible surgical intervention to remove the foreign body, and monitoring for complications. Accurate coding is essential for appropriate management and reimbursement.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Requires understanding of anatomy and injury mechanisms
  • Differentiation from similar codes (e.g., penetrating injuries)
  • Need for detailed documentation of foreign body presence
  • Assessment of associated injuries (e.g., pneumothorax, rib fractures)

Audit Risk Factors

  • Inadequate documentation of the foreign body
  • Failure to document associated injuries
  • Misclassification of the type of laceration
  • Lack of clarity in the mechanism of injury

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Detailed description of the injury mechanism, foreign body identification, and any imaging results.

Common Clinical Scenarios

Patients presenting with trauma from accidents, falls, or assaults with foreign objects.

Billing Considerations

Ensure thorough documentation of vital signs and any immediate interventions performed.

Surgery

Documentation Requirements

Operative reports detailing the removal of foreign bodies and any repair of the thoracic wall.

Common Clinical Scenarios

Surgical intervention for lacerations with foreign bodies requiring exploration and repair.

Billing Considerations

Document any complications or additional procedures performed during surgery.

Coding Guidelines

Inclusion Criteria

Use S21.221 When
  • Follow official ICD
  • CM guidelines for coding injuries, ensuring accurate documentation of the injury site, type, and any foreign bodies present
  • Include any associated injuries in coding

Exclusion Criteria

Do NOT use S21.221 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

12002CPT Code

Simple repair of a laceration

Clinical Scenario

Used when performing a simple repair of the laceration on the thorax.

Documentation Requirements

Document the size and depth of the laceration, as well as any foreign body removal.

Specialty Considerations

Ensure that the procedure is documented in accordance with surgical standards.

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. This specificity aids in better tracking of injury types and outcomes, 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 those with foreign bodies. This specificity aids in better tracking of injury types and outcomes, improving patient care and resource allocation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of injuries, including those with foreign bodies. This specificity aids in better tracking of injury types and outcomes, 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 importance of documenting the foreign body?

Documenting the foreign body is crucial for accurate coding, as it affects the complexity of the injury and potential treatment options. It also impacts reimbursement and the overall management of the patient's care.