2025 ICD-10-CM code S31.111A
Laceration without foreign body of abdominal wall, left upper quadrant without penetration into peritoneal cavity, initial encounter.
Medical necessity for this code is established by the presence of a laceration to the left upper abdominal wall. The documentation must support the diagnosis and treatment provided.
Providers diagnose the condition based on patient history, physical examination of the wound, nerve, and blood supply, and X-rays to assess the damage. Treatment may involve stopping bleeding, cleaning and repairing the wound, applying medication and dressings, pain relievers, antibiotics, tetanus shots, and anti-inflammatory drugs.
- Chapter 19: Injury, poisoning and certain other consequences of external causes (S00-T88)
- S31.1: Open wound of abdominal wall without penetration into peritoneal cavityS31.111: Open wound of abdominal wall, left upper quadrant without penetration into peritoneal cavityS31.111A: Laceration without foreign body of abdominal wall, left upper quadrant without penetration into peritoneal cavity, initial encounter
In simple words: A deep cut or tear in the upper left side of your belly, but not deep enough to go into your abdominal cavity.There is no object stuck in the wound. This code is used for the first time you see a doctor for this injury.
Laceration without foreign body of abdominal wall, left upper quadrant without penetration into peritoneal cavity, initial encounter.
Example 1: A patient presents to the emergency room after falling on a sharp object, resulting in a laceration to the left upper quadrant of the abdominal wall. The wound is cleaned, debrided, and sutured. The laceration does not penetrate the peritoneum, and there is no foreign body present., During a sporting event, a player is struck by another player's cleats, resulting in a deep cut to their left upper abdomen. Upon examination, it's determined the laceration did not penetrate the peritoneal cavity and there is no foreign body in the wound., A patient undergoes surgery. Following the procedure, the patient develops a superficial laceration to the left upper quadrant of their abdominal wall at the surgical site. The wound is superficial and requires minimal intervention.
Documentation should include details of the injury mechanism, location and depth of the laceration, presence or absence of a foreign body, involvement of the peritoneum, associated injuries, and treatment provided.
- Payment Status: Active
- Specialties:Emergency Medicine, General Surgery, Trauma Surgery
- Place of Service:Emergency Room - Hospital, Office, Inpatient Hospital, Outpatient Hospital,Ambulatory Surgical Center