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ICD-10 Guide
ICD-10 CodesS31.613

S31.613

Billable

Laceration without foreign body of abdominal wall, right lower quadrant with penetration into peritoneal cavity

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

Code Description

ICD-10 S31.613 is a billable code used to indicate a diagnosis of laceration without foreign body of abdominal wall, right lower quadrant with penetration into peritoneal cavity.

Key Diagnostic Point:

S31.613 refers to a specific type of abdominal wall injury characterized by a laceration in the right lower quadrant that penetrates the peritoneal cavity without the presence of a foreign body. This condition typically arises from traumatic events such as motor vehicle accidents, falls, or penetrating injuries. The peritoneal cavity is a potential space within the abdomen that houses various organs, including the intestines, liver, and reproductive organs. When a laceration penetrates this cavity, it can lead to serious complications such as peritonitis, hemorrhage, or organ damage. Clinical evaluation often involves imaging studies like CT scans to assess the extent of the injury and determine the need for surgical intervention. Emergency surgical procedures may be required to repair the laceration, control bleeding, and prevent infection. Accurate coding of this condition is crucial for appropriate treatment planning and reimbursement.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Requires detailed documentation of the injury mechanism.
  • Involves assessment of potential organ involvement.
  • Differentiation from similar abdominal injuries.
  • Need for precise anatomical localization.

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury.
  • Failure to note associated organ injuries.
  • Misclassification of the type of laceration.
  • Lack of imaging study documentation.

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Thorough documentation of the patient's clinical presentation, mechanism of injury, and any imaging or surgical interventions performed.

Common Clinical Scenarios

Patients presenting with abdominal trauma from accidents or falls, requiring immediate assessment and potential surgical intervention.

Billing Considerations

Emergency physicians must ensure that all findings are documented clearly to support the coding of complex injuries.

General Surgery

Documentation Requirements

Detailed operative reports that describe the surgical approach, findings, and repairs made during the procedure.

Common Clinical Scenarios

Surgical repair of abdominal wall lacerations with peritoneal involvement, often following trauma.

Billing Considerations

Surgeons should document any complications or additional procedures performed to ensure accurate coding.

Coding Guidelines

Inclusion Criteria

Use S31.613 When
  • According to ICD
  • 10 coding guidelines, S31
  • 613 should be used when there is a documented laceration of the abdominal wall in the right lower quadrant with penetration into the peritoneal cavity
  • Coders must ensure that the documentation supports the diagnosis and that any associated injuries are also coded appropriately

Exclusion Criteria

Do NOT use S31.613 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

49000CPT Code

Exploratory laparotomy

Clinical Scenario

Used when surgical intervention is required to explore and repair the laceration.

Documentation Requirements

Operative report detailing the findings and repairs made during the procedure.

Specialty Considerations

General surgeons must ensure that all findings are documented to support the coding of the procedure.

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 patient care through detailed documentation of injuries.

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 patient care through detailed documentation of injuries.

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 patient care through detailed documentation of injuries.

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 S31.613 accurately?

Accurate coding of S31.613 is crucial for appropriate reimbursement, ensuring that the complexity of the injury is recognized and that the patient receives the necessary care and follow-up.