Laceration without foreign body of lower back and pelvis with penetration into retroperitoneum
ICD-10 S31.011 is a billable code used to indicate a diagnosis of laceration without foreign body of lower back and pelvis with penetration into retroperitoneum.
S31.011 refers to a specific type of laceration that occurs in the lower back and pelvis, characterized by the absence of a foreign body and the penetration into the retroperitoneal space. This injury typically results from blunt or penetrating trauma, such as motor vehicle accidents, falls, or stab wounds. The retroperitoneum is a space in the abdominal cavity that contains vital structures, including the kidneys, ureters, aorta, and inferior vena cava. Injuries in this area can lead to significant complications, including hemorrhage, organ damage, and infection. Emergency surgical intervention is often required to repair the laceration, control bleeding, and prevent further complications. Accurate coding of this condition is crucial for appropriate treatment planning and reimbursement, as it reflects the severity and complexity of the injury. Proper documentation must detail the mechanism of injury, the extent of the laceration, and any associated injuries to ensure comprehensive coding and billing.
Operative reports must detail the nature of the laceration, surgical interventions performed, and any complications encountered.
Trauma from vehicular accidents, falls, or assaults leading to lacerations in the lower back and pelvis.
Ensure that all relevant anatomical details and surgical findings are documented to support the coding.
Emergency department notes should include the mechanism of injury, initial assessment findings, and any imaging results.
Patients presenting with acute trauma to the lower back and pelvis requiring immediate evaluation.
Timely documentation is critical for accurate coding and billing, especially in acute settings.
Used when surgical intervention is required for laceration repair.
Operative report must detail the findings and procedures performed.
Trauma surgeons should ensure all relevant details are captured for accurate coding.
Accurate coding of S31.011 is crucial for reflecting the severity of the injury, guiding treatment decisions, and ensuring appropriate reimbursement for the healthcare provider.
