Puncture wound with foreign body of abdominal wall, right upper quadrant with penetration into peritoneal cavity
ICD-10 S31.640 is a billable code used to indicate a diagnosis of puncture wound with foreign body of abdominal wall, right upper quadrant with penetration into peritoneal cavity.
A puncture wound with a foreign body in the right upper quadrant of the abdominal wall indicates a significant injury that may involve the liver, gallbladder, or other abdominal organs. This type of injury often results from penetrating trauma, such as a stab wound or a gunshot wound, and can lead to serious complications, including internal bleeding, peritonitis, or organ damage. The presence of a foreign body complicates the clinical picture, as it may necessitate surgical intervention to remove the object and repair any damage to the abdominal wall or underlying structures. Patients may present with abdominal pain, tenderness, and signs of peritoneal irritation. Immediate assessment and imaging studies, such as ultrasound or CT scans, are crucial for evaluating the extent of the injury and planning appropriate surgical management. Emergency surgical interventions may include exploratory laparotomy or laparoscopy to address any internal injuries and to ensure the foreign body is safely extracted.
Detailed operative reports, imaging studies, and notes on the mechanism of injury.
Management of stab wounds, gunshot wounds, and other penetrating abdominal injuries.
Accurate coding requires thorough documentation of all findings and interventions during surgery.
Comprehensive patient assessment, including vital signs, physical exam findings, and initial imaging results.
Initial evaluation and stabilization of trauma patients presenting with abdominal injuries.
Timely documentation is critical to ensure accurate coding and billing.
Used when surgical intervention is required for penetrating abdominal injuries.
Operative report detailing findings and interventions.
Trauma surgeons must document the mechanism of injury and any foreign bodies encountered.
Specifying the foreign body is crucial for accurate coding and billing, as it impacts the complexity of the case and the required surgical interventions.
