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2025 ICD-10-CM code S01.01XA

Laceration without foreign body of the scalp, initial encounter.

Use additional codes for any associated injuries (e.g., cranial nerve injury, intracranial injury), infection, or retained foreign body (Z18.-).Use of 7th character 'A' for initial encounter and 'D' for subsequent encounter.

Modifiers may be used to indicate the location of service, the nature of the procedure, or the type of provider.

The medical necessity is established by the presence of a scalp laceration requiring medical attention for appropriate wound care, pain management, infection prevention, and to rule out complications such as skull fractures.

The clinical responsibility involves the physician's assessment of the laceration, determining the need for imaging studies, wound care, and potential antibiotic and tetanus prophylaxis.The physician also oversees the management of pain and inflammation.

IMPORTANT:S01.01XS (sequela),S01.02XA (laceration with foreign body), S01.03XA (puncture wound without foreign body), S01.04XA (puncture wound with foreign body).

In simple words: This code describes a deep cut or tear on the scalp that doesn't have any foreign objects left inside.A doctor will examine the cut, and may take X-rays, clean it, stitch it up, and give you medicine for pain and infection.

This code classifies an irregular, deep cut or tear in the scalp tissue without any retained foreign object.The injury typically involves some bleeding, initially at least. Diagnosis is based on patient history, physical examination (focusing on the wound), and potentially imaging (e.g., X-rays) to rule out fractures or contamination. Treatment may include hemostasis, wound cleaning and debridement, repair, topical medication and dressing, analgesics, NSAIDs, antibiotics (if infection is present), and tetanus prophylaxis (if contamination is suspected).

Example 1: A patient presents to the emergency department after a fall, resulting in a 2cm laceration to the scalp. The wound is cleaned, debrided, and closed with sutures.The patient is prescribed an analgesic and given tetanus prophylaxis.Code S01.01XA is used., A child sustains a scalp laceration during a playground accident. The wound is superficial and does not require suturing. The physician cleans and applies a dressing. Code S01.01XA is used., A patient presents to a clinic with a scalp laceration that occurred 2 days prior. It is not actively bleeding, and there is a small amount of purulent exudate at the wound site. The laceration is cleaned, debrided, and treated with antibiotics. S01.01XA is used with an additional code to specify the infection.

Complete patient history including mechanism of injury, physical examination findings (location, size, depth of laceration, presence of foreign body, bleeding), treatment provided (wound cleaning, debridement, closure method, medication administered, tetanus prophylaxis), and any complications.

** This code is specific to the initial encounter for the laceration.A subsequent encounter would require a different 7th character.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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