In simple words: This code is for the long-term effects of a small hole in the scalp caused by something sharp, like a needle or nail, where nothing was left in the wound.

This ICD-10-CM code classifies a sequela (a condition that is a late effect of a previous injury) of a puncture wound to the scalp that did not involve a retained foreign body.The initial injury resulted in a penetrating wound, creating a small hole in the scalp's skin. This code is used when the patient is experiencing the delayed consequences of the puncture wound, such as pain, swelling, or scarring.

Example 1: A patient presents to the clinic 3 months after sustaining a puncture wound to the scalp from a nail. They now experience persistent pain and a small, raised scar at the injury site.Code S01.03XS is used to reflect the sequelae of the healed puncture wound., A child received a puncture wound to the scalp during a playground accident several weeks ago. The wound has healed, but the patient now reports intermittent numbness in the area.S01.03XS is appropriate to document the lingering neurological sequela., Following a motor vehicle accident resulting in a scalp laceration and puncture wound, the patient's wound has healed completely. However, the patient is reporting persistent headaches and a visible scar. S01.03XS is used.

Patient history detailing the mechanism of injury, date of injury, and description of the initial wound. Documentation of the current examination findings, including description of the scar, presence of any neurological deficits, and any pain reported by the patient.

** Excludes birth trauma (P10-P15) and obstetric trauma (O70-O71).