2025 ICD-10-CM code S31.5
Open wound of unspecified external genital organs.
Medical necessity is established by the presence of an open wound requiring medical intervention. The documentation should support the need for the specific treatment provided (e.g., wound cleaning, repair, medication).
Providers diagnose this condition based on patient history of trauma and physical examination, including assessment of the wound, nerve, and blood supply. Imaging like X-rays or ultrasound might be used. Treatment focuses on stopping bleeding, cleaning and repairing the wound, topical medications, dressings, pain relief, antibiotics, and possibly tetanus prophylaxis. Restricting activities that could worsen the injury is also advised.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the abdomen, lower back, lumbar spine, pelvis and external genitals (S30-S39)
In simple words: An open wound on the external genitals, where the exact location isn't specified.
An open wound of unspecified external genital organs refers to a break in the skin or mucous membrane of the external genital organs, with or without bleeding. The provider does not document the specific site of the injury to the external genital organs.
Example 1: A patient presents with a laceration to the scrotum following a bicycle accident. The exact location on the scrotum is not specified., A female patient experiences a tear in the labia minora during childbirth. The documentation does not specify the precise area of the tear., A male patient sustains an open wound to the penis during a physical altercation.The documentation doesn't detail the specific location of the wound on the penis.
Documentation should include the evidence of an open wound to the external genitalia.Details about the cause of the injury, the presence and extent of bleeding, associated symptoms (pain, tenderness, discharge, etc.), and any diagnostic methods used (physical exam, imaging) should also be documented.
** This code excludes traumatic amputation of external genital organs (S38.21, S38.22).It also excludes open fracture of pelvis.
- Specialties:Emergency Medicine, Urology, Obstetrics and Gynecology, General Surgery
- Place of Service:Emergency Room - Hospital, Office, Inpatient Hospital, Outpatient Hospital