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ICD-10 Guide
ICD-10 CodesS31.6

S31.6

Billable

Open wound of abdominal wall with penetration into peritoneal cavity

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

Code Description

ICD-10 S31.6 is a billable code used to indicate a diagnosis of open wound of abdominal wall with penetration into peritoneal cavity.

Key Diagnostic Point:

An open wound of the abdominal wall with penetration into the peritoneal cavity is a serious condition often resulting from trauma, such as stab wounds, gunshot wounds, or blunt force injuries. This type of injury can lead to significant complications, including peritonitis, hemorrhage, and organ damage. The peritoneal cavity houses vital organs, and any breach in the abdominal wall can expose these organs to external contaminants, increasing the risk of infection. Clinical assessment typically involves imaging studies, such as CT scans, to evaluate the extent of the injury and any associated organ damage. Emergency surgical intervention is often required to repair the abdominal wall, control bleeding, and address any injuries to internal organs. The management of such wounds necessitates a multidisciplinary approach, including trauma surgeons, emergency medicine specialists, and critical care teams, to ensure optimal patient outcomes.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Requires detailed documentation of the mechanism of injury.
  • Involves assessment of associated organ injuries.
  • May necessitate multiple surgical interventions.
  • Requires understanding of trauma protocols and guidelines.

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury.
  • Failure to document associated organ injuries.
  • Lack of clarity on the surgical interventions performed.
  • Inconsistent coding of complications or follow-up care.

Specialty Focus

Medical Specialties

Trauma Surgery

Documentation Requirements

Detailed operative reports, imaging studies, and patient history.

Common Clinical Scenarios

Management of stab wounds, gunshot wounds, and blunt abdominal trauma.

Billing Considerations

Accurate documentation of the extent of injury and surgical findings is crucial for coding.

Emergency Medicine

Documentation Requirements

Initial assessment notes, imaging results, and treatment plans.

Common Clinical Scenarios

Acute presentations of abdominal trauma in the emergency department.

Billing Considerations

Timely documentation of the patient's condition and interventions is essential for accurate coding.

Coding Guidelines

Inclusion Criteria

Use S31.6 When
  • According to ICD
  • 10 guidelines, S31
  • 6 should be used when there is clear documentation of an open wound with penetration into the peritoneal cavity
  • Coders must ensure that the documentation supports the diagnosis and any associated procedures performed

Exclusion Criteria

Do NOT use S31.6 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

49000CPT Code

Exploratory laparotomy

Clinical Scenario

Used in cases of open abdominal wounds with peritoneal penetration.

Documentation Requirements

Operative report detailing findings and interventions.

Specialty Considerations

Trauma surgeons must document the extent of injury and any repairs performed.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of abdominal injuries, improving the accuracy of claims and facilitating better tracking of trauma-related outcomes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of abdominal injuries, improving the accuracy of claims and facilitating better tracking of trauma-related outcomes.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of abdominal injuries, improving the accuracy of claims and facilitating better tracking of trauma-related 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 is the significance of coding S31.6 accurately?

Accurate coding of S31.6 is crucial for proper reimbursement, tracking of trauma cases, and ensuring that patients receive appropriate care based on the severity of their injuries.