Lacerations and Open Wounds ICD-10-CM codes

Open wounds are coded by body region: S01 head, S11 neck, S21 thorax, S31 abdomen and back, S41 upper arm, S51 forearm, S61 wrist, hand, and fingers, S71 hip and thigh, S81 knee and lower leg, S91 ankle, foot, and toes. Within each subcategory the fifth character gives the wound type: 0 unspecified open wound, 1 laceration without foreign body, 2 laceration with foreign body, 3 puncture wound without foreign body, 4 puncture wound with foreign body, 5 open bite. The scalp codes show the pattern: S01.01XA laceration without foreign body, S01.02XA laceration with foreign body, S01.03XA puncture wound without foreign body.

Where the site allows, a sixth character adds laterality or the specific digit: S81.011A is a laceration without foreign body of the right knee, and S61.219A a laceration of an unspecified finger without damage to the nail. Finger wounds are split between S61.2- (without nail damage) and S61.3- (with nail damage, S61.319A). The seventh character is A for the initial encounter, including the visit at which the wound is repaired, D for subsequent care such as suture removal, and S for sequela.

Report only the open wound code when a laceration overlies a contusion or abrasion of the same site; superficial injuries (S00, S60, S80 and so on) are coded separately only when they are at a different site. When a wound becomes infected, add the infection code such as cellulitis L03.113 (right upper limb). A foreign body that is left in place is reported with a Z18 code (Z18.10 retained metal fragments). Tetanus immunization given at the visit is Z23. On the initial encounter add the external cause (W26.0XXA contact with a knife) and place of occurrence codes.