2025 ICD-10-CM code S20.211D
Contusion of right front wall of thorax, subsequent encounter.
This code is exempt from the Present on Admission (POA) reporting requirement.
Medical necessity is established by the clinical findings supporting the diagnosis of a contusion and the need for ongoing care. Documentation should support the reason for the subsequent encounter, such as ongoing pain, new or worsening symptoms, or the need for follow-up of treatment.
Diagnosis is based on patient history, physical exam, and imaging (X-ray, CT scan). Treatment can range from pain medication, ice, to surgery, depending on the severity.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the thorax (S20-S29)
In simple words: This code describes a bruised right front side of the chest, without a break in the skin.It's used when it's not the first time you're seeing a doctor for this injury.
A contusion (bruise) on the front right side of the chest wall, without broken skin. This code is used for subsequent encounters, meaning it's not the initial visit for this injury.
Example 1: A patient presents for a follow-up appointment after being diagnosed with a contusion of the right front wall of the thorax in the emergency room a week prior.The patient is still experiencing pain and some bruising., A patient was injured in a car accident two weeks ago and was diagnosed with a contusion. They are now experiencing increased pain and difficulty breathing and are returning for further evaluation. The code S20.211D would be used for this subsequent encounter., A patient initially seen for a right-sided chest contusion after a fall is seen again a few days later due to worsening pain.They now report difficulty taking a deep breath.S20.211D is used for the follow-up visit to assess the developing symptoms.
Documentation should include the location and severity of the contusion, the mechanism of injury, associated symptoms, and treatment provided.
** Excludes1: birth trauma (P10-P15), obstetric trauma (O70-O71). This code is exempt from the Present on Admission (POA) reporting requirement.
- Payment Status: Active
- Specialties:Emergency Medicine, Family Medicine, Internal Medicine, General Surgery, Trauma Surgery
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Emergency Room - Hospital