Start New EnglishEspañol中文РусскийالعربيةTiếng ViệtFrançaisDeutsch한국어Tagalog Library Performance
BETA v.3.0

2025 ICD-10-CM code S01.03XA

Puncture wound of the scalp without a foreign body, initial encounter.

Use secondary codes from Chapter 20 (External causes of morbidity) to indicate the cause of the injury. An additional code (Z18.-) should be used to identify any retained foreign body, if applicable.

Medical necessity for treatment is based on the nature and severity of the injury.Treatment is necessary to prevent infection, control bleeding, and promote proper wound healing.

Diagnosis is based on patient history of trauma and physical exam focusing on the wound, nerves, and blood supply. Treatment includes stopping bleeding, cleaning and debriding the wound, repairing the wound, applying topical medication and dressing, and administering pain relievers, anti-inflammatory drugs, antibiotics (if infection is present), and tetanus prophylaxis.

In simple words: A piercing injury to the scalp, creating a small hole in the skin, without any object lodged inside.This is for the first time you are seen for this injury.

A puncture wound of the scalp without retention of a foreign body. This code applies to the initial encounter.

Example 1: A patient presents to the emergency room after accidentally puncturing their scalp with a sharp pencil. The wound is cleaned and dressed, and the patient is given a tetanus booster., A child falls while playing and hits their head on a nail sticking out of a fence, resulting in a puncture wound to the scalp. The wound is irrigated and closed with sutures., During a construction accident, a worker receives a small puncture wound to the scalp from a falling piece of metal.The wound is evaluated for foreign bodies, cleaned, and dressed appropriately.

Documentation should include the cause and location of the injury, the size and depth of the wound, presence or absence of foreign bodies, any associated symptoms (pain, bleeding, numbness, etc.), treatment provided, and follow-up instructions.

** This code specifically refers to puncture wounds *without* a retained foreign body. If a foreign body is present, use code S01.04XA.This code is for the initial encounter. For subsequent encounters, use code S01.03XD.

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

Discover what matters.

iFrame™ AI's knowledge is aligned with and limited to the materials uploaded by users and should not be interpreted as medical, legal, or any other form of advice by iFrame™.