2025 ICD-10-CM code S01.02XA
Laceration with foreign body of scalp, initial encounter.
Medical necessity is established by the presence of a scalp laceration with a retained foreign body requiring medical intervention.
A laceration of the scalp with a foreign body may involve pain at the injury site, bleeding, numbness (from nerve damage), bruising, swelling, and inflammation. Diagnosis is based on the patient's account of the injury and a physical exam focusing on the wound, nerves, and blood supply. Treatment might include stopping bleeding, cleaning the wound, removing the foreign object, and closing the wound. Topical medications, dressings, pain relievers, anti-inflammatory drugs, antibiotics (if there's infection), and a tetanus shot may also be necessary.
- S00-T88 Injury, poisoning and certain other consequences of external causes
- Injuries to the head (S00-S09)
In simple words: This code describes a deep cut or tear on the scalp with something stuck in it (like a piece of glass) during the first visit to a healthcare professional for this injury.
A laceration of the scalp with a retained foreign body. This code applies to the initial encounter.
Example 1: A patient presents to the emergency room after falling and hitting their head on a broken bottle. The wound on their scalp is deep and has glass fragments embedded., A child is playing in the park and runs into a tree branch. A piece of the branch breaks off and becomes lodged in a laceration on their scalp., A construction worker is struck by a falling piece of debris. The debris penetrates the worker's scalp, creating a laceration with a retained foreign body.
Documentation should include the cause of the injury, the location and depth of the laceration, presence and description of any foreign bodies, associated symptoms, and treatment provided (e.g., wound cleaning, foreign body removal, wound closure, medications).
- Specialties:Emergency Medicine, General Surgery, Plastic Surgery
- Place of Service:Emergency Room - Hospital, Office, Inpatient Hospital, Outpatient Hospital, Urgent Care Facility