Laceration without foreign body of abdominal wall, left upper quadrant without penetration into peritoneal cavity
ICD-10 S31.111 is a billable code used to indicate a diagnosis of laceration without foreign body of abdominal wall, left upper quadrant without penetration into peritoneal cavity.
S31.111 refers to a specific type of abdominal wall injury characterized by a laceration in the left upper quadrant that does not involve any foreign body and does not penetrate the peritoneal cavity. This injury is often the result of blunt or penetrating trauma, such as from a fall, motor vehicle accident, or an assault. Clinically, it is important to assess the depth and extent of the laceration, as well as to rule out any associated injuries to internal organs, such as the spleen or left kidney, which are located in this quadrant. The absence of penetration into the peritoneal cavity is a critical factor, as it significantly reduces the risk of intra-abdominal complications, such as peritonitis or hemorrhage. Management typically involves wound care, possible suturing, and monitoring for signs of infection or other complications. Emergency surgical intervention may be required if there are signs of internal bleeding or if the laceration is extensive. Accurate coding of this injury is essential for appropriate treatment planning and reimbursement.
Detailed documentation of the injury mechanism, assessment findings, and treatment provided.
Patients presenting with abdominal trauma from falls, accidents, or assaults.
Ensure that all relevant imaging and lab results are included to rule out internal injuries.
Comprehensive surgical notes detailing the procedure performed, findings, and post-operative care.
Surgical intervention for extensive lacerations or those with associated organ injuries.
Document any intraoperative findings that may affect coding and billing.
Used for lacerations requiring simple closure.
Document the size and location of the laceration.
Ensure that the procedure aligns with the diagnosis.
S31.111 is used for lacerations that do not penetrate the peritoneal cavity, while S31.112 is for lacerations that do penetrate, indicating a more severe injury that may require different management.
