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ICD-10 Guide
ICD-10 CodesS31.611

S31.611

Billable

Laceration without foreign body 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 S31.611 is a billable code used to indicate a diagnosis of laceration without foreign body of abdominal wall, left upper quadrant with penetration into peritoneal cavity.

Key Diagnostic Point:

S31.611 refers to a specific type of abdominal wall injury characterized by a laceration in the left upper quadrant that penetrates the peritoneal cavity without the presence of a foreign body. This type of injury is often the result of blunt or penetrating trauma, such as from a motor vehicle accident, falls, or stab wounds. The peritoneal cavity is a potential space within the abdomen that houses various organs, including the stomach, spleen, and parts of the intestines. When a laceration penetrates this cavity, it can lead to serious complications such as internal bleeding, peritonitis, or organ damage. Immediate assessment and intervention are critical to manage these risks. Emergency surgical intervention may be required to repair the laceration, control bleeding, and prevent infection. Accurate coding of this condition is essential for appropriate treatment planning and reimbursement, as it reflects the severity and complexity of the injury.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Requires understanding of anatomical terminology related to the abdominal wall and peritoneal cavity.
  • Differentiation from other abdominal injuries, including those with foreign bodies.
  • Need for precise documentation of the mechanism of injury and extent of damage.
  • Potential for associated injuries in adjacent organs, complicating coding.

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury.
  • Failure to specify the extent of the laceration.
  • Misclassification of the injury type (e.g., coding as superficial when it is deep).
  • Lack of clarity on associated injuries or complications.

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Detailed documentation of the injury mechanism, vital signs, and any immediate interventions performed.

Common Clinical Scenarios

Patients presenting with abdominal trauma from accidents, falls, or violence.

Billing Considerations

Timely documentation is crucial due to the acute nature of the injuries and the need for rapid surgical intervention.

General Surgery

Documentation Requirements

Operative reports must detail the findings during surgery, including the extent of the laceration and any repairs performed.

Common Clinical Scenarios

Surgical repair of abdominal wall lacerations with or without associated organ injuries.

Billing Considerations

Accurate coding is essential for surgical procedures and follow-up care.

Coding Guidelines

Inclusion Criteria

Use S31.611 When
  • According to ICD
  • 10 coding guidelines, S31
  • 611 should be used when the laceration is documented as penetrating into the peritoneal cavity without foreign bodies
  • Coders must ensure that the documentation supports the diagnosis and reflects the severity of the injury

Exclusion Criteria

Do NOT use S31.611 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

49002CPT Code

Exploratory laparotomy, peritoneal cavity

Clinical Scenario

Used when surgical intervention is required for lacerations penetrating the peritoneal cavity.

Documentation Requirements

Operative report detailing the findings and procedures performed.

Specialty Considerations

General surgeons must ensure accurate coding for reimbursement.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of injuries, such as S31.611, which provides a clearer picture of the patient's condition and the complexity of care required.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, such as S31.611, which provides a clearer picture of the patient's condition and the complexity of care required.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of injuries, such as S31.611, which provides a clearer picture of the patient's condition and the complexity of care required.

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 S31.611 accurately?

Accurate coding of S31.611 is crucial for appropriate treatment planning, reimbursement, and tracking of trauma cases. It reflects the severity of the injury and the potential need for surgical intervention.