ICD-10 Coding for Laceration(S31.614, S61.422A)
Complete ICD-10-CM coding and documentation guide for Laceration. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Laceration
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S31.614 | Laceration of abdominal wall, left lower quadrant with penetration into peritoneal cavity | Use when the laceration penetrates the peritoneal cavity. |
|
| S61.422A | Laceration with foreign body of right hand, initial encounter | Use for lacerations with embedded foreign bodies. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for laceration with foreign body
Essential facts and insights about Laceration
Primary ICD-10-CM Codes for laceration
Decision Criteria
clinical Criteria
- Peritoneal penetration confirmed by imaging or surgery
Applicable To
- Penetrating abdominal laceration
Excludes
- Non-penetrating abdominal injuries
Clinical Validation Requirements
- Operative report confirming peritoneal penetration
- Imaging showing pneumoperitoneum
Code-Specific Risks
- Misclassification if penetration is not confirmed
Coding Notes
- Ensure documentation specifies penetration to use this code.
S61.422A - Laceration with foreign body of right hand, initial encounter
Use for lacerations with embedded foreign bodies.
Applicable To
- Laceration with embedded glass or metal
Excludes
- Superficial injuries without foreign body
Clinical Validation Requirements
- Clinical notes detailing foreign body presence
- Radiographic evidence of foreign body
Coding Notes
Ensure foreign body is documented in clinical notes.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Laceration to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S31.614.
Impact
Clinical: Inaccurate clinical picture, Regulatory: Non-compliance with coding standards, Financial: Potential for denied claims
Mitigation Strategy
Always check for and document foreign bodies, Use imaging if necessary
Impact
Reimbursement: Potential underpayment due to incorrect code selection, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate clinical data
Mitigation Strategy
Always document wound dimensions in centimeters.
Impact
Inaccurate or missing wound dimensions can lead to audit findings.
Mitigation Strategy
Implement a checklist for documenting wound details.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Laceration, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Laceration
Use these documentation templates to ensure complete and accurate documentation for Laceration. These templates include all required elements for proper coding and billing.
Emergency Department Laceration Repair
Specialty: Emergency MedicineRequired Elements
- Wound location
- Size in cm
- Depth and layers involved
- Foreign body presence
- Repair method
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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