2025 ICD-10-CM code S00.401D
(Active) Effective Date: N/A Injury - Injuries to the head (S00-S09) Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Unspecified superficial injury of right ear, subsequent encounter.
Medical necessity is established by the presence of a superficial injury to the right ear requiring medical attention. Subsequent encounters are medically necessary if the injury requires ongoing care or monitoring.
A superficial injury of the right ear may result in pain in the affected area that leads to swelling, inflammation, and tenderness. Providers diagnose the condition on the basis of the patient’s personal history and physical examination. Treatment options include administration of analgesics to reduce pain; dressing, cleaning, and application of antibiotic ointment to avoid infection and to stop the bleeding; adhesive strips, and surgical repair if required.
In simple words: This code describes a minor skin injury to the right ear, like a scrape, that is being treated after the initial visit.It is used when the doctor doesn't specify the type of injury during a follow-up appointment.
Unspecified superficial injury of the right ear involves a minimal scrape or wound with minimal, if any, bleeding or swelling of the affected area due to a fall, accident, or surgery. This code is reported for a subsequent encounter when the provider does not document the nature of the injury.
Example 1: A patient presents for a follow-up appointment after falling and injuring their right ear. The initial injury was documented as a superficial injury. During the follow-up, the provider does not specify the type of injury (e.g., abrasion, contusion) and only notes that the ear is healing well., A patient had a surgical procedure involving the right ear and returns for a postoperative check-up. The incision site is healing well, and the provider notes no complications. The documentation does not specify the nature of the initial surgical injury., A patient was seen a week prior for a superficial injury to the right ear. They present again with complaints of increased pain. The provider examines the ear and documents signs of infection, but does not describe the initial injury.
Documentation should support a superficial injury to the right ear.For subsequent encounters, if the nature of the initial injury (e.g., abrasion, blister) is not specified by the provider, this code can be used.
** Excludes1: birth trauma (P10-P15), obstetric trauma (O70-O71).Excludes2: burns and corrosions (T20-T32), effects of foreign body in ear (T16).
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