Injury to stomach, with open wound into cavity

This code signifies a traumatic injury to the stomach where the wound penetrates through the stomach wall, creating an open communication with the abdominal cavity. This typically involves a laceration, puncture, or perforation of the stomach from an external force. It indicates a significant and potentially life-threatening injury requiring immediate surgical intervention.

Apply this code when documentation clearly states a penetrating injury to the stomach, such as a stab wound or gunshot wound, that has entered the peritoneal cavity. This diagnosis is supported by operative reports detailing a stomach perforation or laceration, or imaging studies confirming a full-thickness gastric wall defect with evidence of intra-abdominal spillage.

• Differentiate from superficial stomach injuries or contusions that do not penetrate the cavity.
• Always code external cause of injury (E-code) in addition to this diagnosis.
• Look for specific documentation of "perforation," "laceration with penetration," or "open wound into cavity" of the stomach.