2025 ICD-10-CM code S61.011A
Laceration without foreign body of right thumb without damage to nail, initial encounter.
Medical necessity for treatment is based on the severity of the laceration, including depth, bleeding, and potential for infection or functional impairment.
Providers diagnose the condition based on the patient’s history and physical examination, particularly to assess the nerves, bones, and blood vessels, depending on the depth and severity of the wound, and imaging techniques such as X–rays to determine the extent of damage and to evaluate for foreign bodies. Treatment options include control of any bleeding; immediate thorough cleaning of the wound, debridement and repair of the wound; application of appropriate topical medication and dressing; and analgesics and nonsteroidal antiinflammatory drugs for pain, antibiotics to prevent or treat an infection, and tetanus prophylaxis if necessary.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the wrist, hand and fingers (S60-S69)
In simple words: A deep cut or tear on the right thumb without any object stuck in it and without damage to the nail. This is for the first doctor's visit for this injury.
Laceration without foreign body of right thumb without damage to nail, initial encounter.
Example 1: A patient presents to the emergency room with a deep cut on their right thumb after accidentally cutting it with a kitchen knife. The nail is intact, and there is no foreign object in the wound., A child falls on a playground and sustains a laceration to their right thumb.Examination reveals a clean cut without foreign body or nail damage., During a woodworking project, a patient sustains a laceration to their right thumb. An X-ray confirms no foreign bodies are present, and the nail remains undamaged.
Documentation should include the cause, location, and depth of the laceration, the presence or absence of foreign bodies and nail involvement, associated symptoms, and treatment provided.
- Specialties:Emergency Medicine, Family Medicine, General Surgery, Hand Surgery, Orthopedic Surgery
- Place of Service:Office, Home, Inpatient Hospital, On Campus-Outpatient Hospital, Emergency Room - Hospital,Ambulatory Surgical Center,Military Treatment Facility,Public Health Clinic,Rural Health Clinic, Urgent Care Facility,Telehealth Provided in Patient’s Home, Telehealth Provided Other than in Patient’s Home