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ICD-10 Guide
ICD-10 CodesS31.2

S31.2

Billable

Open wound of penis

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

Code Description

ICD-10 S31.2 is a billable code used to indicate a diagnosis of open wound of penis.

Key Diagnostic Point:

An open wound of the penis refers to a laceration or puncture that disrupts the integrity of the skin and underlying tissues of the penile shaft. This injury can occur due to various mechanisms, including trauma from accidents, surgical procedures, or self-inflicted injuries. The clinical presentation may include bleeding, pain, and potential exposure of underlying structures such as the corpus cavernosum or urethra. In cases of significant trauma, associated injuries may involve the pelvic region, including fractures or damage to the genitourinary system. Emergency management often requires thorough assessment to rule out complications such as urethral injury or infection. Surgical intervention may be necessary to repair the wound, control bleeding, and restore normal anatomy and function. Proper documentation of the mechanism of injury, extent of the wound, and any associated injuries is crucial for accurate coding and treatment planning.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of potential causes (trauma, surgical, self-inflicted)
  • Need for detailed documentation of associated injuries
  • Potential for complications requiring additional coding
  • Variability in treatment approaches based on injury severity

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to document associated injuries
  • Incorrect coding of complications
  • Lack of clarity in surgical intervention details

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed description of the injury, associated symptoms, and any surgical interventions performed.

Common Clinical Scenarios

Traumatic injuries from accidents, surgical complications, or infections.

Billing Considerations

Ensure accurate documentation of any urethral involvement or additional genitourinary injuries.

Emergency Medicine

Documentation Requirements

Comprehensive assessment of the injury, including vital signs, mechanism of injury, and initial treatment provided.

Common Clinical Scenarios

Acute trauma cases presenting to the emergency department.

Billing Considerations

Document any immediate interventions and the need for surgical consultation.

Coding Guidelines

Inclusion Criteria

Use S31.2 When
  • Follow official ICD
  • CM guidelines for coding injuries, ensuring specificity in documenting the type and location of the wound
  • Include any relevant external cause codes to indicate the mechanism of injury

Exclusion Criteria

Do NOT use S31.2 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

54000CPT Code

Incision and drainage of abscess, penis

Clinical Scenario

Used when an abscess develops in conjunction with an open wound.

Documentation Requirements

Document the size, location, and nature of the abscess.

Specialty Considerations

Urology specialists should ensure accurate coding for any surgical interventions.

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 open wounds of the penis, which enhances the ability to track and analyze these injuries for better clinical outcomes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including open wounds of the penis, which enhances the ability to track and analyze these injuries for better clinical outcomes.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of injuries, including open wounds of the penis, which enhances the ability to track and analyze these injuries for better clinical outcomes.

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 are the common causes of open wounds of the penis?

Common causes include traumatic injuries from accidents, surgical complications, and self-inflicted injuries. Each case requires careful assessment to determine the appropriate treatment and coding.