2025 ICD-10-CM code S31
Open wound of abdomen, lower back, pelvis and external genitals.This code also includes any associated spinal cord injury and wound infection.
Seventh character is required to indicate the episode of care (A, D, or S for initial encounter, subsequent encounter, and sequela, respectively).
Medical necessity is established by the nature and severity of the open wound.The need for treatment, including wound closure, pain management, infection prevention, and surgical intervention, should be documented.
Providers diagnose this condition based on the patient's history, a physical exam of the wound, and imaging studies (like X-rays). Treatment typically involves stopping any bleeding, cleaning and dressing the wound, and possibly surgery if needed. Medications like painkillers, antibiotics, tetanus prevention, and anti-inflammatory drugs might also be prescribed.
In simple words: An open wound means a break in the skin or tissues in the area of the abdomen, lower back, pelvis, and genitals. This could be a cut, tear, or other type of injury where the inside of the body is exposed.
Open wound of abdomen, lower back, pelvis and external genitals. Includes injuries to the abdominal wall, anus, buttock, external genitalia, flank, and groin.Code also any associated: spinal cord injury (S24.0, S24.1-, S34.0-, S34.1-) wound infection.Excludes1: traumatic amputation of part of abdomen, lower back and pelvis (S38.2-, S38.3) Excludes2: open wound of hip (S71.00-S71.02) open fracture of pelvis (S32.1--S32.9 with 7th character B)
Example 1: A patient falls from a ladder and sustains a deep laceration to the lower abdomen, exposing underlying muscle tissue., A patient is involved in a motor vehicle accident and presents with an open wound to the pelvis, with associated fractures., A patient undergoes surgery for appendicitis and develops a post-operative wound infection at the incision site in the lower abdomen.
Documentation should include the type and location of the open wound, the mechanism of injury, associated injuries (e.g., fractures, spinal cord injury), depth and extent of the wound, presence of foreign bodies, signs of infection, and treatment provided.
- Specialties:Emergency medicine, Trauma surgery, General surgery
- Place of Service:Emergency Room - Hospital, Inpatient Hospital, Outpatient Hospital, Office