2025 ICD-10-CM code S01.402
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Injury - Injuries to the head (S00-S09) Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Unspecified open wound of the left cheek and temporomandibular area.
Medical necessity is established by the presence of an open wound requiring treatment to prevent infection, promote healing, and alleviate pain.Documentation should support the extent and severity of the wound to justify the treatment provided.
Diagnosis and treatment of the open wound, which may include hemostasis (stopping bleeding), wound cleaning and debridement (removal of damaged tissue), wound repair, application of topical medication and dressings, and administration of analgesics (pain relievers), antibiotics, tetanus prophylaxis, and NSAIDs (nonsteroidal anti-inflammatory drugs) as needed.Imaging techniques, such as X-rays, may also be used for diagnosis.Management of any resulting infection is also within the clinical responsibility.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the head (S00-S09)
In simple words: This code describes an open wound (a break in the skin) on the left side of the face, near the jaw.It can include bleeding, pain, swelling, or infection. Doctors use this code to bill for diagnosis and treatment.
This ICD-10-CM code classifies an unspecified open wound located on the left cheek and temporomandibular joint area.The wound is defined as a break in the skin or mucous membrane, with or without bleeding.The code encompasses various presentations, including pain, swelling, infection, inflammation, and potential restriction of jaw movement. Diagnosis relies on patient history, physical examination (including assessment of jaw mobility), and potentially imaging studies (like X-rays). Treatment may involve hemostasis, wound cleaning and debridement, repair, topical medication/dressing, analgesics, antibiotics, tetanus prophylaxis, NSAIDs, and/or treatment of any resulting infection.
Example 1: A patient presents to the emergency department after a fight, with a laceration to the left cheek near the temporomandibular joint.The wound is cleaned, debrided, and sutured.Analgesics and antibiotics are prescribed., A child falls and sustains a deep abrasion to the left cheek and temporomandibular area.The wound is cleaned and dressed, and tetanus prophylaxis is administered., A patient is involved in a motor vehicle accident and sustains a complex laceration to the left cheek and temporomandibular joint, requiring surgical repair.The patient experiences significant pain and swelling. Post-operative antibiotics and pain management are required.
Detailed description of the wound (location, size, depth, presence of foreign bodies), mechanism of injury, assessment of jaw mobility, imaging studies (if performed), treatment rendered (including type and amount of medication administered), and any complications encountered.
** This code is for unspecified open wounds.More specific codes should be used if the wound has other defining characteristics.Always ensure accurate coding based on the specific clinical documentation.
- Payment Status: Active
- Specialties:Emergency Medicine, Oral and Maxillofacial Surgery, Plastic Surgery
- Place of Service:Emergency Room - Hospital, Office, Ambulatory Surgical Center