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v1.0.0
ICD-10 Guide
ICD-10 CodesS31.601

S31.601

Billable

Unspecified open wound of abdominal wall, left upper quadrant with penetration into peritoneal cavity

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

Code Description

ICD-10 S31.601 is a billable code used to indicate a diagnosis of unspecified open wound of abdominal wall, left upper quadrant with penetration into peritoneal cavity.

Key Diagnostic Point:

An unspecified open wound of the abdominal wall in the left upper quadrant that penetrates into the peritoneal cavity is a serious condition often resulting from trauma. This type of injury can occur due to blunt or penetrating trauma, such as stab wounds or gunshot wounds, and may involve damage to underlying organs such as the spleen, stomach, or left kidney. The peritoneal cavity is a potential space within the abdomen that can become contaminated with bacteria or other pathogens, leading to peritonitis, a severe and potentially life-threatening infection. Patients may present with abdominal pain, tenderness, and signs of internal bleeding. Immediate assessment and intervention are critical, often requiring imaging studies like CT scans to evaluate the extent of the injury. Surgical intervention may be necessary to repair the wound, control bleeding, and prevent infection. The complexity of managing such injuries requires a multidisciplinary approach, including trauma surgeons, radiologists, and critical care specialists.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Variability in presentation and severity of abdominal injuries
  • Need for detailed documentation of the mechanism of injury
  • Potential for multiple organ involvement requiring comprehensive assessment
  • Variability in surgical interventions based on injury specifics

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to specify the extent of the wound
  • Lack of clarity on associated organ injuries
  • Inconsistent coding of surgical procedures performed

Specialty Focus

Medical Specialties

Trauma Surgery

Documentation Requirements

Detailed operative reports, imaging studies, and notes on the mechanism of injury.

Common Clinical Scenarios

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

Billing Considerations

Accurate documentation of the surgical approach and any complications encountered during surgery.

Emergency Medicine

Documentation Requirements

Thorough initial assessment notes, including vital signs and physical examination findings.

Common Clinical Scenarios

Initial evaluation of trauma patients presenting with abdominal injuries.

Billing Considerations

Documentation of the patient's stability and any immediate interventions performed.

Coding Guidelines

Inclusion Criteria

Use S31.601 When
  • Follow official ICD
  • CM coding guidelines, ensuring accurate documentation of the injury's specifics, including the mechanism of injury and any associated complications
  • Ensure that the code reflects the severity and specifics of the wound

Exclusion Criteria

Do NOT use S31.601 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

49000CPT Code

Exploratory laparotomy

Clinical Scenario

Used for surgical exploration of the abdomen in cases of suspected internal injury.

Documentation Requirements

Operative report detailing findings and interventions.

Specialty Considerations

Trauma surgeons must document the extent of the 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 data collection and reimbursement processes. This code reflects the complexity of managing open abdominal wounds with peritoneal involvement.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of abdominal injuries, improving the accuracy of data collection and reimbursement processes. This code reflects the complexity of managing open abdominal wounds with peritoneal involvement.

Reimbursement & Billing Impact

reimbursement processes. This code reflects the complexity of managing open abdominal wounds with peritoneal involvement.

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 specifying the quadrant in abdominal injuries?

Specifying the quadrant is crucial for determining the potential involvement of specific organs and guiding treatment decisions.