2025 ICD-10-CM code S01.04XA
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Injury - Injuries to the head Chapter 19: Injury, poisoning and certain other consequences of external causes Feed
Puncture wound of the scalp with a retained foreign body, initial encounter.
Modifiers may be applicable based on the circumstances of the service (e.g., anesthesia, surgical assistance).
The medical necessity for treatment is established by the presence of a penetrating scalp injury with a retained foreign body.Treatment aims to prevent infection, control bleeding, promote healing, and alleviate pain.Further diagnostic and surgical interventions are deemed necessary based on the depth, location, size, and the type of foreign body involved.
Diagnosis is based on patient history and physical examination, focusing on the wound, nerves, and blood supply. Treatment includes wound care, foreign body removal, pain management, infection prevention, and possible surgical repair.
- Chapter 19: Injury, poisoning and certain other consequences of external causes
- Injuries to the head (S00-S09)
In simple words: This code describes a puncture wound on the scalp where something sharp is stuck inside.It's for the first time this injury is treated.The injury might hurt, bleed, swell, and get infected.Treatment includes cleaning, removing the object, and closing the wound.
This code classifies a penetrating injury to the scalp caused by a sharp object, resulting in a hole in the scalp and a foreign body remaining in the wound.The code is for the initial encounter with this injury.Clinical presentation may include pain, bleeding, bruising, swelling, inflammation, and potential infection. Treatment involves controlling bleeding, wound cleaning and debridement (removal of damaged tissue), foreign body removal, wound repair, topical medication and dressing application, analgesics (pain relievers), NSAIDs (non-steroidal anti-inflammatory drugs), antibiotics (if infection is present), and tetanus prophylaxis (prevention of tetanus).
Example 1: A patient presents after accidentally stepping on a nail, resulting in a puncture wound to the scalp with a retained nail fragment.The wound is cleaned, the nail removed, and the wound sutured.Antibiotics are prescribed., A child falls and sustains a scalp puncture wound from a stick. The patient has a small retained wood splinter. The splinter is removed, the wound cleaned and bandaged, and tetanus prophylaxis administered., A construction worker suffers a scalp injury from a flying shard of metal. The foreign body is deeply embedded.Surgical intervention is necessary to remove the metal fragment. The wound is then cleaned and repaired under sterile conditions.The patient is prescribed prophylactic antibiotics and pain medication.
Patient history describing the mechanism of injury, physical examination findings (including location, depth, and size of wound, presence of foreign body), details of foreign body removal, wound repair techniques, and any prescribed medications (analgesics, antibiotics, tetanus prophylaxis). Imaging (X-rays) may be necessary to identify the foreign body or rule out other injuries.
** This code applies to initial encounters only.Subsequent encounters related to the same injury would require a different code (S01.04XD).
- Payment Status: Active
- Specialties:Emergency Medicine, Neurosurgery, Plastic Surgery
- Place of Service:Emergency Room - Hospital, Office, Ambulatory Surgical Center