2025 ICD-10-CM code S31.832
Laceration with foreign body of the anus.
Medical necessity is established by the presence of a laceration in the anus with a retained foreign body causing symptoms or posing a risk of complications. The need for removal of the foreign body and repair of the laceration should be clearly documented.
A laceration of the anus with retention of a foreign body may result in pain at the affected site, bleeding, swelling, numbness, infection, and inflammation. Providers diagnose the condition on the basis of the patient’s personal history of trauma; a physical examination to assess the wound, nerve, or blood supply; and imaging techniques such as X–rays and ultrasound to rule out hematoma or soft tissue injuries. Treatment options include stoppage of any bleeding; the cleaning and debridement of the wound, and repairing the wound; removal of the foreign object; the application of appropriate topical medication and dressing of the wound; and administering medications such as analgesics, antibiotics, tetanus prophylaxis, and nonsteroidal antiinflammatory drugs (NSAIDs), and/or treatment of any infection.
- 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 anal laceration involves a cut or tear in the anus with a foreign object stuck inside.
A laceration with a foreign body of the anus refers to an irregular deep cut, or tear, in the skin or tissue of the anus, the distal opening of the large intestine, where the wound retains a foreign object.
Example 1: A patient presents with rectal pain and bleeding after inserting a foreign object into their anus. Upon examination, a laceration with the foreign body retained is found., A patient experiences sudden, excruciating pain during defecation. Examination reveals a penetrating foreign body lodged at the anorectal junction, causing a laceration., During a routine colonoscopy, a foreign body is discovered in the rectum, causing a laceration of the anal mucosa.
Documentation should include the type, site, and laterality of the laceration, presence of a foreign body, details of the encounter, and associated symptoms. Imaging reports, operative notes, and other relevant clinical findings should also be documented.
- Specialties:General surgery, Proctology, Emergency medicine
- Place of Service:Emergency Room - Hospital, Inpatient Hospital, Physician's Office, Outpatient Hospital