2025 ICD-10-CM code S01.03XA
(Active) Effective Date: N/A Injury - Open wound of scalp Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Puncture wound of the scalp without a foreign body, initial encounter.
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.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the head (S00-S09)
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.
- Specialties:Emergency Medicine, General Surgery, Family Medicine
- Place of Service:Office, Home, Inpatient Hospital, On Campus-Outpatient Hospital, Emergency Room - Hospital,Ambulatory Surgical Center,Military Treatment Facility,Public Health Clinic,Rural Health Clinic, Other Place of Service