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2025 ICD-10-CM code S31.831

Laceration without a foreign body of the anus.

Follow all applicable ICD-10-CM coding guidelines, including the use of additional codes to specify the cause of injury and any retained foreign bodies.Use of 7th character codes (A, D, S) should reflect the encounter status (initial, subsequent, sequela).

Modifiers may be applicable depending on the circumstances of the procedure and the payer's requirements.

Medical necessity is established by the presence of an anal laceration requiring medical attention. This may include assessment of the wound, bleeding control, wound repair, pain management, and infection prevention. The extent of the laceration and the presence of complications will determine the level of care required.

The clinical responsibility includes diagnosing the laceration through patient history, physical examination, and potentially imaging studies. Treatment involves managing bleeding, cleaning and repairing the wound, administering appropriate medications (analgesics, antibiotics, tetanus prophylaxis, NSAIDs), and addressing any resulting infection.

IMPORTANT:Consider S31.832 (Laceration with foreign body of anus) if a foreign body is present.Additional codes may be necessary to specify associated injuries, such as spinal cord injury (S24.-, S34.-) or wound infection.

In simple words: A laceration of the anus without a foreign body means a deep cut or tear in the skin around the anus that doesn't have anything stuck in it.It can be painful, bleed, swell, and get infected. Doctors will examine the area and may use X-rays or ultrasounds. Treatment might involve cleaning the wound, stitching it up, and giving pain relievers or antibiotics.

This code signifies an irregular deep cut or tear in the anal skin or tissue, the distal end of the large intestine, without any retained foreign object.The injury may present with pain, bleeding, swelling, numbness, infection, and inflammation. Diagnosis involves patient history, physical examination, and imaging (X-rays, ultrasound) to rule out hematomas or soft tissue injuries. Treatment may include bleeding control, wound cleaning and debridement, wound repair, topical medication, dressings, analgesics, antibiotics, tetanus prophylaxis, NSAIDs, and infection treatment.

Example 1: A patient presents after a fall, complaining of anal pain and bleeding. Examination reveals a 2cm laceration without a foreign body. The physician cleans the wound, performs a simple repair, and prescribes antibiotics and analgesics., A child sustains an anal laceration during a bicycle accident.The wound is superficial and doesn't require suturing. The physician cleans the wound, applies antiseptic ointment, and provides pain relief instructions., A patient presents with an anal laceration several days after the event, exhibiting signs of infection. The physician performs wound debridement, sutures the deeper tissues, prescribes intravenous antibiotics, and provides analgesia.

Detailed patient history describing the mechanism of injury, physical examination findings documenting the location, size, and depth of the laceration, and any associated injuries.Imaging studies (if performed) should be documented.Treatment notes, including wound care details and medications administered, are essential.

** Always consider the possibility of associated injuries and code accordingly.Careful documentation is essential for accurate coding and reimbursement.

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