2025 ICD-10-CM code S01.5
Open wound of the lip and oral cavity.
Medical necessity is established by the presence of an open wound in the lip and oral cavity that requires medical attention. The documentation should support the need for the specific treatment provided, such as pain management, wound repair, or infection control.
Physicians typically diagnose this condition based on a patient's history of trauma and a physical examination of the wound. Imaging studies, such as X-rays, might be necessary. Treatment generally involves controlling bleeding, cleaning and repairing the wound, applying medication and dressings, and providing pain relief and antibiotics.A tetanus shot may also be given.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the head (S00-S09)
In simple words: An open wound in the mouth or on the lip. This could be a cut, tear, or other break in the skin inside your mouth or on your lips.
Break in the skin or mucous membrane of the lip and oral cavity, which may or may not involve bleeding.
Example 1: A patient falls and cuts their lip, resulting in an open wound., A patient bites their cheek, causing a tear and open wound inside their mouth., A patient undergoes a dental procedure that results in an accidental laceration to the gums, causing an open wound.
Documentation should include the cause, location, and severity of the wound, any associated injuries, and the treatment provided. Details about the size and depth of the wound, any bleeding or infection, and the type of repair (if any) should be noted.
- Specialties:Emergency Medicine, Dentistry, Oral Surgery, Maxillofacial Surgery, Plastic Surgery
- Place of Service:Office, Emergency Room - Hospital, Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center