2025 ICD-10-CM code S01.04XS
(Active) Effective Date: N/A Injury - Injuries to the head (S00-S09) Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Puncture wound with foreign body of scalp, sequela. This indicates a piercing injury to the scalp with a retained object, resulting in a long-term condition.
Medical necessity for using S01.04XS must be supported by documentation demonstrating the long-term consequences of the initial puncture wound and the retained foreign body.This could include chronic pain, neurological deficits, recurrent infections, or other functional impairments directly related to the injury. The documentation should clearly link the current condition to the original trauma.
Providers diagnose this condition based on patient history and physical examination, focusing on the wound, nerves, and blood supply. Treatment may involve stopping bleeding, cleaning and removing the foreign body, wound repair, topical medication, dressings, pain relievers, anti-inflammatory drugs, antibiotics, and tetanus prophylaxis if infection or contamination is present.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- S01.04XS is a subcategory of S01.04: Puncture wound with foreign body of scalp.S01.04 is under category S01: Open wound of head.
In simple words: This code describes a long-term condition resulting from a puncture wound to the scalp where something is still stuck inside.
A puncture wound of the scalp with a retained foreign body refers to a piercing injury that creates a hole in the skin due to an accident with a sharply pointed object (such as needles, glass, nails, or wood splinters), resulting in an object lodged within the wound. This code specifically applies to a sequela, meaning a condition that is a consequence of the initial injury.
Example 1: A patient presents with a persistent infection resulting from a nail puncture wound to the scalp, where a portion of the nail remains embedded., A child fell on a sharp object, resulting in a puncture wound on their scalp. After the initial wound treatment, they experience chronic headaches and sensitivity around the scar tissue, indicating a sequela from the retained foreign body., Months after a glass shard injury to the scalp, a patient experiences persistent nerve pain and numbness in the affected area, even after the visible wound has healed, due to a retained glass fragment.
Documentation should include details of the initial injury, the type of foreign body, the location and depth of the wound, treatment provided, presence of infection or complications, and any long-term effects experienced by the patient. Imaging reports (X-rays, CT scans) confirming the presence and location of the foreign body are crucial.Follow-up notes documenting the sequelae, such as pain, numbness, or recurrent infections, should also be included.
** For accurate coding, it is important to differentiate between the initial encounter (S01.04XA) for the acute injury and the subsequent encounter (S01.04XD) and the sequela (S01.04XS) for the long-term consequences.
- Specialties:Emergency Medicine, General Surgery, Neurosurgery, Plastic Surgery
- Place of Service:Office, Home, Inpatient Hospital, On Campus-Outpatient Hospital, Emergency Room - Hospital,Outpatient Hospital,Other Place of Service