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2025 ICD-10-CM code S81

Open wound of the knee and lower leg.Includes any associated wound infection.

Use additional codes to identify the cause of injury (Chapter 20) and any retained foreign body (Z18.-).Select the most specific code available to represent the location and type of wound. Consider 7th character for encounter status (A=initial, D=subsequent, S=sequela).

Modifiers may apply depending on the circumstances of the service provided, such as the location, type of service, and who provided it.

Medical necessity is established by the need to repair the open wound to prevent infection, promote healing, and restore function.The severity of the wound and the risk of complications justify the treatment provided.Documentation must support the medical necessity of the treatment.

Diagnosis is based on patient history, physical examination (assessing nerves, bones, and blood vessels), and imaging (like X-rays to check for foreign bodies or extent of damage). Treatment may involve bleeding control, wound cleaning, surgical debridement, wound repair, topical medication, dressings, analgesics, NSAIDs, antibiotics, and tetanus vaccination.

IMPORTANT:More specific codes exist within the S81 category (e.g., S81.0 for open wound of the knee, S81.8 for open wound of the lower leg) depending on the precise location and type of wound.Additional codes may be required 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 injury (like a cut, puncture, or bite) to the knee or lower leg that breaks the skin. It also includes any infection that develops in the wound.

This code classifies open wounds affecting the knee and lower leg.The open wound may be a laceration, puncture wound, or open bite.The code also encompasses any associated wound infection.Excludes open fractures of the knee and lower leg (S82.-), traumatic amputation of the lower leg (S88.-), and open wounds of the ankle and foot (S91.-).

Example 1: A patient presents with a deep laceration on their right knee after a fall, requiring sutures and antibiotic treatment. Code S81.011 (Laceration without foreign body, right knee) would be used., A child sustains a puncture wound to their left lower leg from stepping on a nail. Code S81.8 (Open wound of lower leg) might be used, and an additional code for the cause (stepping on a nail) would be appropriate from Chapter 20., An adult suffers an open bite wound to the knee during a dog attack.Code S81.05 (Open bite of knee) would be utilized.Treatment includes wound cleansing, debridement, and possible antibiotics for infection prevention.

Detailed description of the wound (location, size, depth, type), mechanism of injury, presence of foreign bodies, signs of infection, treatment provided (cleaning, debridement, closure, antibiotics), and any complications. Imaging reports should also be included.

** This code is for open wounds, not closed wounds or fractures.Appropriate coding requires careful documentation and consideration of the specific details of the injury and treatment rendered.

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

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