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2025 ICD-10-CM code S01.10

Unspecified open wound of eyelid and periocular area.

Use additional code(s) from Chapter 20 (External causes of morbidity) to identify the cause of the injury.If a foreign body is retained, use code from Z18.-.

Modifiers may be used to specify the location or other details of the service provided. Consult your specific payer for allowed modifiers.

Medical necessity is established by the presence of an open wound requiring treatment, and justified by the physician’s clinical judgment of the need for the procedure, and supported by the documentation.

The clinical responsibility includes evaluating the patient's history, performing a thorough physical examination of the eyelid and periocular area, diagnosing the wound, providing appropriate treatment (hemostasis, wound cleaning and debridement, wound repair, dressing, and medication), and monitoring for complications like infection.

IMPORTANT:Code also for any associated infection.Additional codes may be necessary to specify the cause of injury (from Chapter 20, External causes of morbidity), and any retained foreign body (Z18.-).

In simple words: This code describes an open wound on the eyelid or the area around the eye.The doctor doesn't specify the type of wound. It might be painful, bleed, swell, get infected, or become inflamed. Treatment might include stopping the bleeding, cleaning the wound, repairing it, applying medicine and bandages, and giving pain relievers.

This code classifies an unspecified open wound affecting the eyelid and the surrounding periocular area.The nature of the wound is not specified in the medical documentation.The condition may present with pain, bleeding, swelling, infection, and inflammation. Diagnosis relies on patient history and physical examination. Treatment might involve hemostasis, wound cleaning and debridement, repair, topical medication, dressings, and analgesics or NSAIDs.

Example 1: A patient presents to the emergency department after a fight, with a laceration to the left eyelid.The wound is cleaned, debrided, and sutured. Code S01.10 is used because the exact nature of the wound is not specified beyond being an open wound., A child falls and sustains an abrasion to the right periocular area. The wound is cleaned and a topical antibiotic ointment is applied. S01.10 is appropriate as the description is an unspecified open wound., During a routine eye exam, a physician discovers a small, open wound on the lower eyelid, likely from an unnoticed injury. No treatment beyond observation is necessary at this time. S01.10 would be utilized because there isn't detailed information describing the type of wound.

Patient's history of the injury, physical examination findings, description of the wound (size, depth, location), treatment provided (including medications, dressings), and any complications noted.

** This code should only be used when the specifics of the open wound (e.g., laceration, abrasion, puncture) are not documented.Always ensure complete documentation of the injury and any associated conditions.

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

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