Puncture wound without foreign body of abdominal wall, unspecified quadrant with penetration into peritoneal cavity
ICD-10 S31.639 is a billable code used to indicate a diagnosis of puncture wound without foreign body of abdominal wall, unspecified quadrant with penetration into peritoneal cavity.
A puncture wound of the abdominal wall occurs when a sharp object penetrates the skin and underlying tissues, resulting in an opening that may extend into the peritoneal cavity. This type of injury can arise from various incidents, including accidents, assaults, or surgical complications. The absence of a foreign body indicates that the wound is not caused by an object that remains lodged within the body. The peritoneal cavity is a potential space within the abdomen that houses various organs, and penetration into this area can lead to serious complications such as peritonitis, hemorrhage, or organ damage. Clinical evaluation typically involves a thorough physical examination, imaging studies, and possibly exploratory surgery to assess the extent of the injury and determine the appropriate intervention. Emergency surgical intervention may be necessary to repair any damage to internal organs, control bleeding, and prevent infection. The management of such wounds requires a multidisciplinary approach, often involving trauma surgeons, emergency medicine physicians, and critical care specialists.
Detailed operative notes, imaging results, and injury assessments.
Management of stab wounds, gunshot wounds, and accidental punctures.
Accurate documentation of the mechanism of injury and any associated organ damage is crucial.
Initial assessment notes, vital signs, and treatment provided in the emergency department.
Patients presenting with abdominal pain after trauma, requiring immediate evaluation.
Timely documentation of the patient's condition and interventions is essential for coding accuracy.
Used when surgical intervention is required for abdominal puncture wounds.
Operative report detailing findings and procedures performed.
Trauma surgeons must document the extent of injury and any repairs made.
Accurate coding of S31.639 is crucial for proper reimbursement, tracking of trauma cases, and ensuring appropriate clinical management of patients with abdominal puncture wounds.
