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ICD-10 Guide
ICD-10 CodesS31.621

S31.621

Billable

Laceration with 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 S31.621 is a billable code used to indicate a diagnosis of laceration with foreign body of abdominal wall, left upper quadrant with penetration into peritoneal cavity.

Key Diagnostic Point:

S31.621 refers to a specific type of abdominal trauma characterized by a laceration in the left upper quadrant of the abdominal wall that has been complicated by the presence of a foreign body and has penetrated into the peritoneal cavity. This condition often arises from penetrating injuries such as stab wounds or gunshot wounds, as well as from blunt trauma that results in the introduction of foreign objects into the abdominal cavity. The presence of a foreign body can lead to significant complications, including infection, peritonitis, and damage to internal organs. Immediate medical evaluation and intervention are critical to assess the extent of the injury, manage any internal bleeding, and prevent further complications. Surgical intervention is often required to remove the foreign body, repair the laceration, and address any damage to surrounding structures, including the spleen, stomach, or intestines. The complexity of this condition necessitates thorough documentation of the injury mechanism, the nature of the foreign body, and any surgical procedures performed.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Presence of a foreign body complicates the coding process.
  • Requires detailed documentation of the injury mechanism.
  • Potential for multiple surgical interventions increases complexity.
  • Need for accurate assessment of internal organ involvement.

Audit Risk Factors

  • Inadequate documentation of the foreign body type and location.
  • Failure to specify the extent of peritoneal cavity involvement.
  • Misclassification of the injury mechanism.
  • Lack of clarity in surgical intervention details.

Specialty Focus

Medical Specialties

Trauma Surgery

Documentation Requirements

Detailed operative notes, imaging results, and injury assessments.

Common Clinical Scenarios

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

Billing Considerations

Accurate documentation of the mechanism of injury and foreign body characteristics is crucial.

Emergency Medicine

Documentation Requirements

Comprehensive initial assessment notes, including vital signs and imaging findings.

Common Clinical Scenarios

Immediate evaluation and stabilization of trauma patients with abdominal injuries.

Billing Considerations

Timely documentation of interventions and patient response is essential for accurate coding.

Coding Guidelines

Inclusion Criteria

Use S31.621 When
  • According to ICD
  • 10 coding guidelines, S31
  • 621 should be used when there is a documented laceration of the abdominal wall in the left upper quadrant with a foreign body and penetration into the peritoneal cavity
  • Coders must ensure that all components of the injury are documented, including the mechanism of injury and any surgical procedures performed

Exclusion Criteria

Do NOT use S31.621 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 the abdominal cavity due to penetrating trauma.

Documentation Requirements

Operative report detailing findings and procedures performed.

Specialty Considerations

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

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of complex injuries like S31.621, improving the accuracy of medical records and facilitating better patient care through detailed documentation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of complex injuries like S31.621, improving the accuracy of medical records and facilitating better patient care through detailed documentation.

Reimbursement & Billing Impact

reimbursement and compliance.

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 S31.621 accurately?

Accurate coding of S31.621 is crucial for proper reimbursement, tracking of trauma cases, and ensuring that patients receive appropriate care based on the severity of their injuries.