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ICD-10 Guide
ICD-10 CodesS31.65

S31.65

Billable

Open bite of abdominal wall with penetration into peritoneal cavity

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

Code Description

ICD-10 S31.65 is a billable code used to indicate a diagnosis of open bite of abdominal wall with penetration into peritoneal cavity.

Key Diagnostic Point:

An open bite of the abdominal wall with penetration into the peritoneal cavity is a traumatic injury characterized by a laceration or puncture wound that breaches the abdominal wall and extends into the peritoneal cavity. This type of injury can occur due to various mechanisms, including animal bites, human bites, or sharp object injuries. The penetration into the peritoneal cavity poses significant risks, including peritonitis, internal bleeding, and damage to abdominal organs such as the intestines, liver, or spleen. Clinical management often requires immediate surgical intervention to assess and repair any damage to internal structures, control bleeding, and prevent infection. The severity of the injury can vary based on the depth and location of the bite, as well as the presence of any associated injuries to the pelvic region or lumbar spine. Prompt diagnosis and treatment are crucial to mitigate complications and improve patient outcomes.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Requires detailed documentation of the mechanism of injury.
  • Assessment of associated injuries to abdominal organs.
  • Need for surgical intervention documentation.
  • Potential for complications such as infection or internal bleeding.

Audit Risk Factors

  • Inadequate documentation of the injury mechanism.
  • Failure to document surgical interventions performed.
  • Misclassification of the injury type.
  • Lack of follow-up documentation regarding complications.

Specialty Focus

Medical Specialties

Trauma Surgery

Documentation Requirements

Detailed operative reports and injury assessments are essential.

Common Clinical Scenarios

Management of traumatic abdominal injuries, including bites and stab wounds.

Billing Considerations

Ensure all surgical findings and interventions are clearly documented.

Emergency Medicine

Documentation Requirements

Accurate initial assessment and triage notes are critical.

Common Clinical Scenarios

Initial evaluation and stabilization of patients with abdominal trauma.

Billing Considerations

Document the mechanism of injury and any immediate interventions performed.

Coding Guidelines

Inclusion Criteria

Use S31.65 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the injury type, mechanism, and any associated injuries
  • Include details of surgical interventions and complications as necessary

Exclusion Criteria

Do NOT use S31.65 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 abdominal trauma.

Documentation Requirements

Operative report detailing findings and interventions.

Specialty Considerations

Trauma surgeons must document all findings and repairs.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of traumatic injuries, including open bites with peritoneal involvement, enhancing the ability to track and manage these complex cases.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of traumatic injuries, including open bites with peritoneal involvement, enhancing the ability to track and manage these complex cases.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of traumatic injuries, including open bites with peritoneal involvement, enhancing the ability to track and manage these complex cases.

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 S31.65 accurately?

Accurate coding of S31.65 is crucial for proper reimbursement, tracking of trauma cases, and ensuring appropriate patient management. It reflects the severity of the injury and the complexity of care required.