Puncture wound of abdominal wall without foreign body, right upper quadrant without penetration into peritoneal cavity
ICD-10 S31.130 is a billable code used to indicate a diagnosis of puncture wound of abdominal wall without foreign body, right upper quadrant without penetration into peritoneal cavity.
A puncture wound of the abdominal wall in the right upper quadrant is characterized by a breach in the skin and underlying tissues without the introduction of a foreign body and without penetration into the peritoneal cavity. This type of injury can occur due to various mechanisms, including accidental trauma from sharp objects or intentional injuries. Clinically, it is essential to assess the wound for signs of infection, bleeding, and any associated injuries to underlying organs, particularly the liver and gallbladder, which are located in the right upper quadrant. The absence of penetration into the peritoneal cavity suggests that the risk of intra-abdominal complications is lower than in cases where such penetration occurs. However, careful monitoring and appropriate management are crucial to prevent potential complications, such as abscess formation or delayed hemorrhage. Treatment typically involves wound care, possible suturing, and monitoring for any signs of complications.
Detailed description of the injury mechanism, assessment findings, and treatment provided.
Patients presenting with stab wounds, accidental punctures from tools, or animal bites.
Ensure that all relevant imaging studies and consultations are documented to support the coding.
Operative reports detailing the surgical intervention, if performed, and post-operative care.
Surgical repair of abdominal wall injuries or management of complications arising from puncture wounds.
Document any findings related to underlying organ injuries during surgical procedures.
Used when the puncture wound requires suturing or closure.
Document the size of the wound and the method of closure.
Ensure that the procedure is linked to the diagnosis of the puncture wound.
Accurate coding of S31.130 is crucial for proper reimbursement, tracking of injury patterns, and ensuring appropriate clinical management of patients with abdominal wall injuries.
