ICD-10 code S31.626S: laceration with foreign body, right flank, sequela

ICD-10 code S31.626S covers a specific, easy-to-miss injury presentation: a laceration to the right flank of the abdominal wall that had an embedded foreign body and penetrated into the peritoneal cavity, now presenting as a late effect after the original wound has healed. Coders sometimes default to a generic open-wound code or the wrong quadrant, which is why this page walks through the exact code structure, the foreign-body distinction, and the sequela sequencing rule that governs how S31.626S is reported.

Key Takeaways

ICD-10 code S31.626S describes a laceration with foreign body of the abdominal wall, right flank, with penetration into the peritoneal cavity, sequela – a fully billable ICD-10-CM diagnosis code.

The ‘S’ seventh character designates a sequela encounter: the patient presents with a condition that is a late effect of a prior wound, not an active or healing wound.

Coders must distinguish S31.626S from S31.626A (initial encounter) and S31.626D (subsequent encounter) – incorrect suffix selection is a common claim denial trigger.

Structured clinical documentation – like the treatment notes and records tools built into practice management software such as Pabau – helps practices capture the causal link a sequela claim needs and reduces coding-related denials.

ICD-10 code S31.626S: definition and clinical description

Most open wound claims are submitted using the initial encounter suffix without a second thought. When a patient returns months later with an ongoing complication tied to a prior abdominal wall injury, the documentation requirements change entirely, and the wrong suffix triggers an immediate denial. ICD-10 code S31.626S is the correct code for that scenario: a laceration with foreign body of the abdominal wall, right flank, with penetration into the peritoneal cavity, sequela.

This code sits within the S31 family in the ICD-10-CM classification system maintained by CMS and covers open wounds of the abdomen, lower back, pelvis, and external genitals. The “.626” extension specifies a laceration with an embedded foreign body in the right flank of the abdominal wall, with penetration into the peritoneal cavity – the space that houses the intestines, stomach, liver, spleen, and other abdominal organs. The trailing “S” designates a sequela encounter type, meaning the patient’s current presentation is a late effect of an original wound, not the wound itself.

S31.626S is a valid, billable ICD-10-CM code confirmed in the CDC/NCHS ICD-10-CM web tool. Coders and billers documenting penetrating abdominal wall trauma will encounter this code alongside other S31 wound classifications when a retained or previously removed foreign body is part of the clinical picture.

Code structure breakdown

Every character in S31.626S carries specific clinical meaning. Understanding the segment logic is the fastest way to avoid miscoding this injury class. Here is what each part communicates:

The foreign-body designation at S31.62 is a critical clinical distinction from S31.61 (laceration without foreign body) and S31.60 (unspecified open wound). A retained foreign body changes both the acute treatment plan – exploration and removal versus simple closure – and the downstream sequela picture, since a missed fragment can itself become the source of a late complication such as a foreign-body granuloma or chronic sinus tract.

The ‘S’ seventh character: sequela encounter type explained

The seventh character in ICD-10-CM injury codes is not a detail – it determines whether a claim processes or denies. For S31.626, three seventh-character options exist, each describing a different phase of patient care.

According to the ICD-10-CM Official Guidelines for Coding and Reporting, Section I.C.19, the three encounter types are defined as follows:

• A (initial encounter): The patient is receiving active treatment for the wound. This applies to the first visit and any visit where definitive treatment is still ongoing, including surgery or wound care procedures.
• D (subsequent encounter): The wound is healing and the patient receives routine care. Follow-up appointments, dressing changes, and suture removal are coded with D when no new definitive treatment is provided.
• S (sequela): The acute wound phase has resolved. The patient now presents with a complication or late effect directly caused by the original wound – for example, a foreign-body granuloma, chronic sinus tract, localized abscess, or persistent abdominal wall pain from the original laceration and foreign body.

For sequela coding, the S suffix applies to the residual condition code, and the injury code S31.626S is sequenced as a secondary code identifying the nature of the sequela. This is a common documentation gap: clinicians document the current condition but fail to link it explicitly to the prior wound, which breaks the clinical chain payers need to process the claim. Proper clinical documentation standards require the attending physician to explicitly state the causal relationship in the encounter note.

S31.626A vs S31.626D vs ICD-10 code S31.626S: encounter type comparison

Selecting the wrong seventh character for laceration coding in the abdominal wall region is one of the most common reasons for claim rejection in trauma-related billing. This comparison table clarifies when each variant applies:

A key coding principle: once a wound has healed, it is no longer coded with A or D. Any visit for a complication arising from that healed wound moves to the S suffix. Using S31.626A for a healed wound with residual effects is a coding error that misrepresents the clinical picture and may be flagged during audit review. Structured documentation workflows – like the treatment notes and records tools built into practice management software such as Pabau – help practices track the original injury details coders need to select the correct seventh character before submission.

Clinical use cases and documentation requirements

ICD-10 code S31.626S applies in a specific clinical window: after the original right-flank abdominal wall laceration and foreign body have been treated and the wound has fully healed, but the patient continues to experience ongoing health consequences traceable to that injury. These are the scenarios where this code is appropriate:

• Foreign-body granuloma: A patient sustained a right-flank abdominal wall laceration with an embedded foreign body six months ago. The wound closed after foreign body removal, but they now present with a palpable granuloma at the injury site attributed to residual foreign material or reactive tissue. The granuloma code leads; S31.626S is the sequela code identifying the originating injury.
• Chronic sinus tract or wound infection sequela: A draining sinus tract persists at the site of the original laceration long after the acute wound has closed. The sinus tract or infection code leads; S31.626S documents the causative wound.
• Localized abdominal wall pain: Persistent pain at the right flank attributable to the original laceration and foreign body, with no signs of an active wound. The pain or neuropathy code is primary; S31.626S is sequenced as secondary.
• Functional impairment: Reduced abdominal wall strength or a ventral hernia developing at the site of the original injury, with a documented causal link to the original laceration.

The documentation requirements for S31.626S are more demanding than for initial or subsequent encounters. Practices need to ensure the following is captured in the encounter note:

• A clear statement from the attending physician linking the current condition to the prior wound
• The date or approximate timeframe of the original injury
• Documentation that the original wound has resolved (distinguishing this from an active healing wound)
• Clinical findings supporting the residual condition being coded as the primary diagnosis

Practices that use structured patient record documentation with templated clinical notes find it easier to capture these sequela-specific details consistently across encounters. Maintaining HIPAA-compliant documentation for injury sequela cases also requires retaining records of the original encounter to support the causal linkage.

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Coding guidelines and compliance notes

The ICD-10-CM Official Guidelines for Coding and Reporting provide specific rules for sequela coding that apply directly to S31.626S. Following these guidelines is essential for claim compliance and audit readiness.

Sequela sequencing rule

When coding a sequela, the residual condition is sequenced first and the injury code with the S suffix is listed as the secondary code. For example: a patient presents with a foreign-body granuloma following a healed right-flank abdominal wall laceration. The granuloma code leads; S31.626S follows as the secondary sequela code. This sequencing rule is frequently reversed in practice, which causes claim rejections.

Active condition vs. sequela distinction

Do not code the original injury (S31.626A or S31.626D) alongside S31.626S in the same encounter. By definition, using the S suffix means the original wound has resolved. Coding both the active wound and the sequela simultaneously misrepresents the clinical picture and can trigger a medical necessity audit.

Tabular instructional notes for this code family

Two instructional notes at the S31 category level apply to S31.626S. A Code Also note flags any associated spinal cord injury (S24.0, S24.1-, S34.0-, S34.1-) or wound infection – code these in addition when documented. Category S31 also carries a Type 1 Excludes note for traumatic amputation of part of the abdomen, lower back, and pelvis (S38.2-, S38.3), and a Type 2 Excludes note for open wound of the hip (S71.00-S71.02) and open fracture of the pelvis (S32.1–S32.9 with 7th character B). A related cross-reference sits at category S36 (injury of intra-abdominal organs): S36 carries its own Code Also note for any associated open wound (S31.-), so when a right-flank laceration with peritoneal cavity penetration also damages an intra-abdominal organ, expect S31.6- and S36.- codes reported together.

Common coding errors for this code family

• Using S31.626A for follow-up visits beyond the initial treatment phase
• Applying S31.626S without physician documentation explicitly linking the current condition to the prior wound
• Failing to code the primary residual condition as the lead code, instead leading with S31.626S
• Submitting without supporting documentation of the original injury date

Building coding compliance checks into the billing workflow reduces these errors systematically rather than relying on individual coder vigilance. Compliance management workflows that flag sequela codes without an accompanying primary residual diagnosis code help catch this specific pattern before submission.

Related ICD-10-CM codes

Understanding where S31.626S fits within the broader S31.6 family helps coders navigate adjacent presentations and select the most precise code for each encounter. The table below shows the most frequently referenced codes in this family alongside codes commonly used in the same encounter.

Coders can use the AAPC Codify ICD-10-CM lookup to browse the full S31 family and verify adjacent codes. For quick lookups, ICD List provides free access to the full ICD-10-CM tabular list. Structured workflows using digital intake forms help capture original injury details – including whether a foreign body was present – at the first encounter, which simplifies sequela documentation at later visits.

Conclusion

Sequela coding for penetrating abdominal wall wounds is one of the trickier areas in injury billing, largely because the documentation burden falls on the physician to make an explicit causal connection that many encounter notes leave implicit. ICD-10 code S31.626S is the correct code for a healed right-flank laceration with foreign body and peritoneal cavity penetration, but its accuracy depends entirely on the clinical record supporting it.

Practices that build sequela documentation checks into their billing workflow, ensure physicians explicitly state causal relationships, and validate seventh-character selection before submission will see fewer denials on this code family. Structured documentation tools – like the treatment notes and records features in practice management software such as Pabau – support this kind of coding compliance workflow at scale. To see how Pabau handles clinical documentation for injury coding, book a demo.

Continue your research

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