In simple words: This code is for a follow-up visit after a small hole was made in the scalp by something sharp, like a needle or piece of glass, with nothing left inside the wound.

This ICD-10-CM code classifies a puncture wound of the scalp without a retained foreign body during a subsequent encounter.It indicates a piercing injury creating a small hole in the scalp's skin, caused by a sharp object (needle, glass, etc.), without any foreign material remaining in the wound.This code is for subsequent visits related to the initial injury.

Example 1: A patient presents to the emergency department after stepping on a nail, resulting in a puncture wound to the scalp.The wound is cleaned and sutured.This initial encounter would be coded differently.A subsequent visit for suture removal would use S01.03XD., A child sustains a scalp puncture wound from a fall onto a sharp object.Following initial treatment at an urgent care facility, the patient returns to their primary care physician's office for a follow up. S01.03XD would be used., An adult suffers a puncture wound to the scalp during a workplace accident. After receiving initial treatment at a workplace clinic, the patient is seen in the physician's office for a follow up. S01.03XD would be utilized.

Documentation should include the patient's history of the injury, physical examination findings (location, depth, size of wound, presence or absence of foreign body, neurovascular status), description of treatment (wound cleaning, debridement, repair, medications administered), and follow up plan.

** Always refer to the most current official ICD-10-CM coding guidelines for the most accurate and up-to-date information.This information is current as of December 3rd, 2024.