ICD-10 code S31.41XD: Laceration of vagina and vulva

Key takeaways

S31.41XD is the billable ICD-10-CM code for a laceration without foreign body of vagina and vulva, subsequent encounter.

The 7th character D covers routine follow-up care, while S31.41XA covers active treatment and S31.41XS covers late effects.

A tear that happened during delivery never uses this code. Chapter 15 codes O70.- and O71.4 cover obstetric lacerations.

The note has to name the wound as a laceration, rule out a retained object, and place it on the vagina or vulva.

Practice management software like Pabau keeps the follow-up note, the diagnosis code, and the claim on one patient record.

ICD-10 code S31.41XD is the billable code for a laceration without foreign body of vagina and vulva, subsequent encounter. It applies at the follow-up visit, once active treatment of the wound is finished.

Denials on this code come from one of two places. Either the 7th character does not match the stage of care, or the tear happened during delivery and belongs in Chapter 15 instead.

What S31.41XD covers, and when you can bill it

S31.41XD describes a cut or tear of the vagina or vulva with no foreign body left in it, coded at a follow-up visit. The code is billable and specific, so it stands on a claim by itself. Nothing sits beneath it in the tabular list.

It is also valid for HIPAA-covered transactions, so every electronic claim can carry it. Medicare, Medicaid, and most commercial payers accept it. The code applies to female patients only, so a sex edit will kick it back on a male patient’s claim.

Coders in emergency medicine, gynecology, and sexual health practices reach for it most often. Each of those claims travels under the HIPAA compliance rules that cover electronic transactions.

S31.41XD at a glance

Here is the code metadata worth confirming before a claim leaves the billing queue. The CMS ICD-10-CM code files are the source of record for each of these fields.

Where the code sits in the ICD-10-CM hierarchy

Every ICD-10-CM code sits on a path that runs from chapter down to billable code. Reading that path shows what S31.41XD already assumes about the injury, so you can spot the point where a different code takes over.

• S00-T88: Injury, poisoning and certain other consequences of external causes (chapter)
• S30-S39: Injuries to the abdomen, lower back, lumbar spine, pelvis and external genitals (block)
• S31: Open wound of abdomen, lower back, pelvis and external genitals (category)
• S31.4: Open wound of vagina and vulva (subcategory)
• S31.41: Laceration without foreign body of vagina and vulva (subcategory)
• S31.41XD: Subsequent encounter (billable code)

Neighboring codes for the same body site follow the same shape. S38.03XA covers a crushing injury of the vulva rather than an open wound, and its path reads the same way. Other categories in the same block are built to match, as S37.011A shows for an internal organ injury.

The “X” in position six is a placeholder, required by ICD-10-CM formatting rules. It holds the sixth slot open so the 7th character can land in the right position. Drop the X and the code is invalid. Payers reject it on the first edit.

The 7th character tells the payer which visit this is

Rejections on this code usually trace back to the 7th character. It signals the episode of care, so it has to match what the provider was doing at that visit.

D is the character for aftercare of an injury, and the guidelines are blunt about it. Aftercare Z codes do not apply to injuries. Report the acute injury code with the subsequent encounter character instead, and keep reporting it until the wound is healed.

That pattern repeats across the whole injury chapter, which is why S01.111D reads as a follow-up visit at a glance. Once healing is finished and a late effect remains, the sequela character takes over, as S30.9AXS shows.

What counts as a laceration without foreign body

A laceration is a tear or cut through the skin and the tissue underneath, caused by blunt or sharp force. The “without foreign body” part of the descriptor confirms that nothing stayed in the wound.

Three elements have to line up before S31.41XD is correct. The wound has to be a laceration, and nothing can be retained in it. The visit also has to be follow-up care rather than active treatment.

A note that describes a puncture sends you to S31.43XD. Wound exploration or imaging that finds a retained object sends you to S31.42XD.

The injuries behind it are usually blunt ones. Straddle falls, bicycle and playground accidents, and sexual assault all show up in these notes. So does penetrating trauma treated in gynecology and OB-GYN practices.

Documentation wording that maps to this code

Providers rarely write the tabular description word for word. These are the phrasings that map to S31.41XD:

• Laceration of vulva without foreign body, subsequent encounter
• Vaginal laceration without foreign body, follow-up visit
• Nonobstetric vaginal tear, no retained object, wound check
• Vulvar laceration, sutures intact, routine follow-up
• Open wound of vulva, laceration type, healing as expected

Obstetric tears never use this code

This is the biggest miscode on the S31.41 family. A vaginal or vulvar tear that happened during delivery belongs in Chapter 15, not the injury chapter.

S31.4 carries an Excludes1 note for injury to the vagina and vulva during delivery. That note points you to O70.- for a perineal laceration during delivery, and to O71.4 for a high vaginal laceration alone. Excludes1 means the two codes never sit on the same claim.

Degree matters in Chapter 15, so the delivery note has to say first, second, third, or fourth degree. O71.9 covers obstetric trauma that the record leaves unspecified.

Follow-up care splits the same way. If a delivery tear or an episiotomy breaks down afterward, report O90.1 for disruption of a perineal obstetric wound. S31.41XD is for follow-up of a laceration that had nothing to do with a birth.

Sibling codes that catch a different wound type

The siblings under S31.4 split on two things: what kind of wound it was, and whether anything stayed behind. Reading them side by side heads off the two most common miscodes.

The rest of the injury chapter is built the same way. A code such as S25.111D separates wound severity and encounter stage in its own body region. S34.21XD applies the same subsequent encounter character to a nerve injury.

How S31.41XD maps back to ICD-9-CM

Legacy charts and old payer records still surface ICD-9-CM codes, so the mapping is worth keeping close. The general equivalence mappings give the official bidirectional crosswalk between the two code sets.

ICD-9-CM separated the vulva from the vagina and stopped there. ICD-10-CM does the reverse. It covers both sites in one code, then adds the wound type and the foreign body status.

ICD-9-CM also had no encounter character, so nothing maps cleanly to the D in S31.41XD. Treat every row above as approximate, and read the original note before converting a historical claim.

What the note has to show before you code it

Payers audit injury claims against the record, so the note carries the whole case. Digital intake forms and structured templates at the point of care keep the required detail from going missing.

Documentation should support each of these elements:

• Wound type confirmed as a laceration: The note names a laceration or tear, not a puncture, abrasion, or contusion. Mechanism of injury helps, so record the straddle fall or the blunt impact.
• No foreign body: The exam confirmed no foreign body, or imaging ruled one out. Document the method used, whether that was visual inspection, X-ray, or ultrasound.
• Anatomical specificity: The note references the vagina, the vulva, or both. “Perineal wound” on its own is not enough for S31.41XD.
• Follow-up care, not active treatment: The visit is a wound check, a suture removal, or a dressing change. Tie it back to the date of the original injury.
• A non-obstetric cause: The record shows the tear did not happen during delivery. That one line keeps the claim out of Chapter 15.
• External cause code: Add a code from Chapter 20 (V00-Y99) with its own D character. W19.XXXD covers an unspecified fall at the follow-up visit.

Excludes notes to check at the category level

S31.41XD carries no excludes notes of its own, so the checks happen one level up. S31.4 has the Excludes1 note for injury during delivery (O70.-, O71.4). Category S31 adds an Excludes1 for traumatic amputation of part of the abdomen, lower back and pelvis (S38.2-, S38.3).

S31 also carries an Excludes2 note, which is easy to miss. It covers open wound of hip (S71.00-S71.02) and open fracture of pelvis with 7th character B (S32.1-S32.9). Excludes2 means the two conditions can happen together, so both codes can sit on the same claim when the note supports both.

One instructional note matters more at a follow-up visit than at the first one. S31 tells you to code also any associated wound infection, and infection is exactly what these wound checks tend to find.

A quick check before you submit

Run the claim past these six points and most edit-level rejections disappear:

• The wound is called a laceration in the provider’s own words.
• A foreign body was ruled out, and the method is named.
• The site is documented as vagina, vulva, or both.
• The record rules out a delivery injury.
• The 7th character matches the stage of care, and the injury date is on file.
• Any external cause code carries the same D character.

From there the claim moves in a predictable order. The provider’s follow-up note lands in the chart.

Your coder assigns S31.41XD plus the external cause code, and the biller attaches the CPT codes for what was done. The claim then goes out with the place of service, the date of injury, and the right NPI types.

Clearinghouse edits catch the formatting problems early. What survives to a payer denial is usually a clinical detail the note never recorded. These records are sensitive, so patient data security matters wherever the documentation travels.

CPT codes that get billed alongside S31.41XD

The diagnosis justifies the procedure, so CPT selection follows what the provider actually did. The table lists the codes that most often accompany a follow-up visit for a vaginal or vulvar laceration.

Check the current AMA CPT code set and your payer’s policy first, since the clinical detail drives the level.

Global periods are where these claims come apart. If the original repair carried a 10-day or 90-day global period, the routine wound check is already paid for inside the surgical fee.

Report 99024 for that visit rather than a separate office visit, and check the repair code on the fee schedule before you bill anything else. Wound closure elsewhere on the body follows the same logic, and 12032 covers intermediate repair in the 2.6 to 7.5 cm range.

Common mistakes that stall these claims

• Coding a delivery tear as an injury. Obstetric lacerations belong to O70.- or O71.4, and S31.4 excludes them outright.
• Coding a puncture as a laceration. The wound type in the note decides the code, and a puncture belongs to S31.43XD.
• Dropping the placeholder X. Without it the 7th character sits in the wrong slot, and the claim fails the first edit.
• Using A for every visit. Follow-up wound checks belong to D, even when the same provider treats the patient.
• Billing an office visit inside the global period. A routine post-repair wound check is reported with 99024 instead.
• Coding from the discharge summary. The treating provider’s follow-up note is what supports the code on audit.

S31.41XD is valid through FY2026

S31.41XD carries into ICD-10-CM fiscal year 2026 unchanged. The FY2026 code set took effect on October 1, 2025, with no revision, deletion, or resequencing for this code.

Codes do move between fiscal years, so confirm status each fall before the October update lands. The CDC ICD-10-CM tool shows the current entry for S31.41XD and the rest of the S31.4 family.

How Pabau keeps injury follow-up coding and claims on one record

In a lot of practices this work is spread across three places. The repair note sits in the chart. Codes live in a spreadsheet or in a coder’s head. Then the claim gets rebuilt again in the billing system. Every hand-off is a chance for the wound type or the encounter stage to drift.

Practice management software like Pabau keeps those pieces together. The repair note, the follow-up note, the diagnosis code, and the invoice sit on the same patient record. Your coder works from the provider’s own wording instead of a summary. Pabau’s claims management then checks the insurer fields a claim needs before it goes out.

For a subsequent encounter code, that history is the whole argument. The record shows when active treatment ended and when follow-up began, so the 7th character is easy to defend on audit. Your team spends less time hunting for the note that proves the claim.

Keep injury follow-up notes and claims in one place

Pabau brings the repair note, the follow-up visit, the ICD-10-CM code, and the claim together on one patient record. Insurer fields get checked before submission, so your billing team stops rebuilding the same visit twice.

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Conclusion

Follow-up claims for a vaginal or vulvar laceration turn on three lines in the record. They show what kind of wound it was, whether anything stayed in it, and whether a birth caused it. Confirm those three, then let the 7th character follow the stage of care.

When one of these claims does come back, read the note before you touch the code. The fix is usually a documentation detail rather than a coding one, and the same detail tends to go missing again next month. Tightening the charting template is what stops the repeat.

Book a demo to see how Pabau keeps injury notes, ICD-10-CM codes, and claims together on one patient record.

Continue your research

Was the wound a puncture instead? S01.341A covers a puncture wound with a retained foreign body at another site.

Working on a delivery tear instead? O71.9 shows how Chapter 15 handles obstetric trauma the record leaves unspecified.

Coding a late effect rather than active care? S30.9AXS shows how the sequela character works once treatment is finished.

Billing the repair itself? 12032 explains intermediate wound repair and the sizing rules that come with it.

Want notes that hold up on audit? Safer clinical notes walks through how to record injuries and treatment so the documentation supports the code.

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