Laceration without foreign body of unspecified back wall of thorax with penetration into thoracic cavity
ICD-10 S21.419 is a billable code used to indicate a diagnosis of laceration without foreign body of unspecified back wall of thorax with penetration into thoracic cavity.
S21.419 refers to a laceration of the back wall of the thorax that does not involve a foreign body and has penetrated into the thoracic cavity. This type of injury is often the result of blunt or penetrating trauma, such as from a fall, motor vehicle accident, or stab wound. The thoracic cavity houses vital organs, including the lungs and heart, making such injuries potentially life-threatening. Clinically, patients may present with symptoms such as chest pain, difficulty breathing, or signs of shock. Diagnostic imaging, such as chest X-rays or CT scans, is crucial for assessing the extent of the injury and ruling out complications like pneumothorax (air in the pleural space) or hemothorax (blood in the pleural space). Management may involve surgical intervention to repair the laceration and address any associated injuries, such as rib fractures or cardiac injuries. Close monitoring for complications is essential in the acute care setting.
Detailed operative reports and imaging studies.
Management of penetrating trauma, rib fractures, and thoracotomy.
Ensure all associated injuries are documented for accurate coding.
Thorough initial assessment and treatment notes.
Acute chest trauma, assessment of pneumothorax or hemothorax.
Document vital signs and any interventions performed in the ED.
Used for patients presenting with severe chest trauma.
Document the severity of the condition and any interventions performed.
Emergency medicine specialists should ensure thorough documentation of the patient's condition.
Performed for repair of thoracic laceration.
Operative report detailing the procedure and findings.
Trauma surgeons must document all findings and interventions.
S21.419 is used for lacerations without foreign bodies, while S21.411 is for lacerations with foreign bodies present.
