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ICD-10 Guide
ICD-10 CodesS21.222

S21.222

Billable

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

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

Code Description

ICD-10 S21.222 is a billable code used to indicate a diagnosis of laceration with foreign body of left back wall of thorax without penetration into thoracic cavity.

Key Diagnostic Point:

S21.222 refers to a specific type of chest trauma characterized by a laceration on the left back wall of the thorax, which is complicated by the presence of a foreign body. Importantly, this condition does not involve penetration into the thoracic cavity, which distinguishes it from more severe thoracic injuries. Such lacerations can occur due to various mechanisms, including blunt or penetrating trauma, and may be associated with other injuries such as rib fractures, pneumothorax, or hemothorax. The presence of a foreign body can complicate the clinical picture, potentially leading to infection or further tissue damage. Management typically involves careful assessment to rule out deeper injuries, removal of the foreign body, and appropriate wound care. In cases where there is concern for underlying thoracic injuries, imaging studies such as chest X-rays or CT scans may be warranted to evaluate for complications like pneumothorax or hemothorax. The absence of penetration into the thoracic cavity is a critical factor in determining the treatment approach and potential surgical interventions.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Presence of foreign body complicates the clinical picture.
  • Differentiation from other thoracic injuries requires careful assessment.
  • Potential for associated injuries such as rib fractures or pneumothorax.
  • Documentation must clearly indicate the absence of thoracic cavity penetration.

Audit Risk Factors

  • Inadequate documentation of the foreign body.
  • Failure to specify the location of the laceration.
  • Misclassification of the injury as penetrating.
  • Lack of imaging documentation to support the diagnosis.

Specialty Focus

Medical Specialties

Trauma Surgery

Documentation Requirements

Detailed operative notes describing the laceration, foreign body removal, and any associated injuries.

Common Clinical Scenarios

Management of traumatic chest injuries, including lacerations with foreign bodies.

Billing Considerations

Ensure clear documentation of the mechanism of injury and any imaging results.

Emergency Medicine

Documentation Requirements

Thorough initial assessment notes, including vital signs and imaging results.

Common Clinical Scenarios

Initial evaluation and stabilization of patients with chest trauma.

Billing Considerations

Document all findings related to the laceration and any potential complications.

Coding Guidelines

Inclusion Criteria

Use S21.222 When
  • According to ICD
  • CM guidelines, S21
  • 222 should be used when a patient presents with a laceration of the left back wall of the thorax with a foreign body, without penetration into the thoracic cavity
  • It is essential to document the mechanism of injury and any associated injuries

Exclusion Criteria

Do NOT use S21.222 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

12002CPT Code

Simple repair of a laceration, face, ears, eyelids, scalp; 2.5 cm or less

Clinical Scenario

Used when performing a simple repair of the laceration.

Documentation Requirements

Document the size and location of the laceration.

Specialty Considerations

Ensure that the repair is documented as simple or complex based on the nature of the laceration.

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 trauma cases and improves the quality of care through enhanced data collection.

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 trauma cases and improves the quality of care through enhanced data collection.

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 trauma cases and improves the quality of care through enhanced data collection.

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 should be documented to support the use of S21.222?

Documentation should include the mechanism of injury, details of the laceration, presence of a foreign body, and imaging results that confirm no penetration into the thoracic cavity.