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ICD-10 Guide
ICD-10 CodesS31.30

S31.30

Billable

Unspecified open wound of scrotum and testes

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

Code Description

ICD-10 S31.30 is a billable code used to indicate a diagnosis of unspecified open wound of scrotum and testes.

Key Diagnostic Point:

An unspecified open wound of the scrotum and testes refers to a traumatic injury that results in a break in the skin and underlying tissues of the male genitalia, specifically affecting the scrotum and/or testes. This type of injury can occur due to various mechanisms, including blunt trauma, penetrating injuries, or lacerations. Such wounds may be associated with significant bleeding, risk of infection, and potential damage to the reproductive organs. Clinical evaluation often involves assessing the extent of the injury, potential involvement of surrounding structures, and the need for surgical intervention. Emergency management may include wound care, hemostasis, and possibly surgical repair, depending on the severity and nature of the wound. The complexity of treatment can vary widely, from simple suturing to more extensive surgical procedures if there is significant tissue loss or damage to the testes. Accurate coding is essential for proper reimbursement and tracking of healthcare outcomes related to trauma care.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in injury severity and type
  • Potential for associated injuries in the pelvic region
  • Need for detailed documentation of trauma mechanism
  • Differentiation from other genitourinary injuries

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to specify the extent of the wound
  • Lack of surgical notes if intervention was performed
  • Inconsistent coding with clinical findings

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed notes on the nature of the injury, surgical interventions performed, and follow-up care.

Common Clinical Scenarios

Traumatic injuries from sports, accidents, or assaults leading to open wounds.

Billing Considerations

Ensure clarity on whether the injury involves the scrotum, testes, or both for accurate coding.

Emergency Medicine

Documentation Requirements

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

Common Clinical Scenarios

Patients presenting with acute trauma to the genital area requiring urgent care.

Billing Considerations

Document all interventions and consultations with urology for potential surgical repair.

Coding Guidelines

Inclusion Criteria

Use S31.30 When
  • Follow official ICD
  • CM coding guidelines, ensuring that the code is used only when the specific nature of the wound is not documented
  • Include additional codes for any associated injuries or complications

Exclusion Criteria

Do NOT use S31.30 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

54000CPT Code

Incision and drainage of abscess, scrotum

Clinical Scenario

Used when there is an associated abscess requiring drainage.

Documentation Requirements

Document the size and location of the abscess, as well as the procedure performed.

Specialty Considerations

Urology specialists should ensure that the procedure is linked to the diagnosis of an open wound.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of injuries, which can improve the accuracy of data collection and reimbursement processes. S31.30 provides a framework for capturing unspecified injuries while encouraging detailed documentation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, which can improve the accuracy of data collection and reimbursement processes. S31.30 provides a framework for capturing unspecified injuries while encouraging detailed documentation.

Reimbursement & Billing Impact

reimbursement processes. S31.30 provides a framework for capturing unspecified injuries while encouraging detailed documentation.

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 should I document to support the use of S31.30?

Document the mechanism of injury, the extent of the wound, any surgical interventions performed, and follow-up care to ensure accurate coding.