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ICD-10 Guide
ICD-10 CodesS31.625

S31.625

Billable

Laceration with foreign body of abdominal wall, periumbilic region with penetration into peritoneal cavity

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

Code Description

ICD-10 S31.625 is a billable code used to indicate a diagnosis of laceration with foreign body of abdominal wall, periumbilic region with penetration into peritoneal cavity.

Key Diagnostic Point:

S31.625 refers to a specific type of abdominal trauma characterized by a laceration in the abdominal wall, particularly in the periumbilical region, that is complicated by the presence of a foreign body. This condition indicates that the laceration has penetrated into the peritoneal cavity, which can lead to serious complications such as peritonitis, hemorrhage, and damage to internal organs. The periumbilical area is a critical region where various abdominal organs are located, and any injury here necessitates immediate medical evaluation and intervention. The presence of a foreign body complicates the injury, as it may introduce infection or cause additional trauma to surrounding structures. Emergency surgical intervention is often required to remove the foreign body, repair the laceration, and assess for any internal injuries. Proper coding of this condition is essential for accurate medical billing and to ensure that the patient receives appropriate care.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Presence of a foreign body complicates the injury.
  • Potential for multiple internal injuries requiring assessment.
  • Need for emergency surgical intervention.
  • Variability in documentation based on the extent of injury.

Audit Risk Factors

  • Inadequate documentation of the foreign body.
  • Failure to document the extent of internal injuries.
  • Misclassification of the injury severity.
  • Lack of clarity in surgical notes regarding the procedure performed.

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Detailed notes on the mechanism of injury, assessment findings, and interventions performed.

Common Clinical Scenarios

Patients presenting with stab wounds, gunshot wounds, or accidental injuries involving foreign objects.

Billing Considerations

Ensure that all findings related to the foreign body and any internal injuries are clearly documented.

General Surgery

Documentation Requirements

Operative reports must detail the surgical approach, findings, and any repairs made to the abdominal wall and internal organs.

Common Clinical Scenarios

Surgical intervention for lacerations with foreign bodies, including exploratory laparotomy.

Billing Considerations

Accurate coding of surgical procedures performed in conjunction with the laceration repair.

Coding Guidelines

Inclusion Criteria

Use S31.625 When
  • According to ICD
  • 10 guidelines, S31
  • 625 should be used when there is a documented laceration with a foreign body that has penetrated the peritoneal cavity
  • Coders must ensure that the documentation supports the diagnosis and includes details about the foreign body and any surgical interventions

Exclusion Criteria

Do NOT use S31.625 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

49000CPT Code

Exploratory laparotomy

Clinical Scenario

Used when surgical intervention is required for laceration repair and assessment of internal injuries.

Documentation Requirements

Operative report detailing the findings and procedures performed.

Specialty Considerations

General surgeons must ensure that all aspects of the surgery are documented for accurate coding.

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 such as S31.625, improving the accuracy of medical records and billing. This specificity helps in better tracking of trauma cases and outcomes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of complex injuries such as S31.625, improving the accuracy of medical records and billing. This specificity helps in better tracking of trauma cases and outcomes.

Reimbursement & Billing Impact

billing. This specificity helps in better tracking of trauma cases and 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 S31.625 accurately?

Accurate coding of S31.625 is crucial for proper reimbursement, tracking of trauma cases, and ensuring that patients receive appropriate care. It reflects the complexity of the injury and the necessary interventions.