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Home/Diagnosis/ICD-10 Coding for Open Wound of the Right Lower Leg

ICD-10 Coding for Open Wound of the Right Lower Leg

S81.801A
S81.812A

Complete ICD-10-CM coding and documentation guide for icd-10 coding for open wound of the right lower leg includes clinical validation requirements, medical necessity guidelines, and coding policies.

Also Known as:
Right Lower Leg Laceration
Right Lower Leg Puncture Wound
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Key Information: ICD-10 Coding for Open Wound of the Right Lower Leg

Essential facts and insights about ICD-10 Coding for Open Wound of the Right Lower Leg

Use ICD-10 code S81.801A for unspecified open wound, right lower leg, initial encounter, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Unspecified open wound, right lower leg, initial encounter

Billable Code
S81.801A
Billable

Diagnostic Criteria

documentation_criteria:
  • • Wound type is not specified
applicable_to:
  • • Unspecified laceration
  • • Unspecified puncture
excludes:
  • • Open fracture (S82.-)
  • • Traumatic amputation (S88.-)
validation:
  • • Documentation of wound location
  • • Absence of specific wound type
notes:
  • • Ensure documentation specifies wound type to avoid using unspecified codes.
risks:
  • • Risk of claim denial due to lack of specificity

Laceration without foreign body, right lower leg, initial encounter

Billable Code
S81.812A
Billable

Diagnostic Criteria

applicable_to:
  • • Clean laceration
excludes:
  • • Laceration with foreign body (S81.812A)
validation:
  • • Documentation of laceration type
  • • Absence of foreign body
notes:
  • • Ensure documentation clearly states absence of foreign body.
Ancillary Codes

Additional codes that may be used with this diagnosis

T81.05xA

Retained foreign body fragments

Use when foreign body fragments are present in the wound.

Frequently Asked Questions

What is the ICD-10 code for an open wound of the right lower leg?

The ICD-10 code for an unspecified open wound of the right lower leg, initial encounter, is S81.801A. For a laceration without foreign body, use S81.812A.

When should S81.801A be used?

Use S81.801A when the type of open wound on the right lower leg is not specified in the documentation.

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