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ICD-10 Guide
ICD-10 CodesS31.659

S31.659

Billable

Open bite of abdominal wall, unspecified quadrant with penetration into peritoneal cavity

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

Code Description

ICD-10 S31.659 is a billable code used to indicate a diagnosis of open bite of abdominal wall, unspecified quadrant with penetration into peritoneal cavity.

Key Diagnostic Point:

An open bite of the abdominal wall refers to a traumatic injury characterized by a laceration or puncture that penetrates the skin and underlying tissues, potentially reaching the peritoneal cavity. This type of injury can occur due to various mechanisms, including animal bites, sharp objects, or other forms of trauma. The unspecified quadrant indicates that the injury does not have a specific location within the abdominal wall, which can complicate diagnosis and treatment. Penetration into the peritoneal cavity raises the risk of peritonitis, organ injury, and significant internal bleeding, necessitating immediate medical evaluation and intervention. Patients may present with abdominal pain, signs of infection, or shock, depending on the severity of the injury. Emergency surgical intervention is often required to repair the abdominal wall, assess for internal injuries, and prevent complications. The management of such injuries involves a multidisciplinary approach, including trauma surgeons, emergency medicine physicians, and possibly specialists in infectious disease or gastroenterology.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Need for precise documentation of the injury mechanism and location
  • Potential for associated injuries in adjacent organs
  • Variability in clinical presentation and severity
  • Requirement for surgical intervention and follow-up care

Audit Risk Factors

  • Inadequate documentation of the injury mechanism
  • Failure to note associated injuries or complications
  • Misclassification of the injury quadrant
  • Lack of surgical notes detailing the intervention

Specialty Focus

Medical Specialties

Trauma Surgery

Documentation Requirements

Detailed operative reports, including injury assessment and repair techniques.

Common Clinical Scenarios

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

Billing Considerations

Accurate documentation of the extent of injury and any associated organ damage is crucial.

Emergency Medicine

Documentation Requirements

Comprehensive notes on patient presentation, initial assessment, and any imaging studies performed.

Common Clinical Scenarios

Initial evaluation of trauma patients presenting with abdominal pain or injury.

Billing Considerations

Timely documentation is essential for coding and billing, especially in acute settings.

Coding Guidelines

Inclusion Criteria

Use S31.659 When
  • According to ICD
  • 10 coding guidelines, this code should be used when there is a confirmed open bite of the abdominal wall with penetration into the peritoneal cavity
  • Coders must ensure that documentation supports the diagnosis and that any associated injuries are also coded appropriately

Exclusion Criteria

Do NOT use S31.659 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 open abdominal injuries.

Documentation Requirements

Operative report detailing findings and interventions.

Specialty Considerations

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

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of abdominal injuries, improving the accuracy of data collection and reimbursement processes. S31.659 provides a clear framework for documenting complex abdominal trauma.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of abdominal injuries, improving the accuracy of data collection and reimbursement processes. S31.659 provides a clear framework for documenting complex abdominal trauma.

Reimbursement & Billing Impact

reimbursement processes. S31.659 provides a clear framework for documenting complex abdominal trauma.

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 specifying the quadrant in coding?

Specifying the quadrant helps in understanding the extent of the injury and potential complications, which is crucial for treatment planning and coding accuracy.