2025 ICD-10-CM code S01.409S
(Active) Effective 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 unspecified cheek and temporomandibular area, sequela.
Medical necessity is established by the ongoing symptoms, functional limitations, or complications arising as a direct result of the previous open wound in the specified area. The documentation must clearly link the current condition to the previous injury.
Diagnosis is based on patient history of trauma, physical examination assessing the wound and jaw mobility, and imaging like X-rays. Treatment includes stopping bleeding, cleaning and repairing the wound, topical medication, dressings, pain relievers, antibiotics, tetanus prophylaxis, and anti-inflammatory drugs.The clinical responsibility lies with the healthcare provider managing the wound and its after-effects.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the head (S00-S09)
In simple words: This code refers to a long-term complication or after-effect of an open wound on the cheek or the area around the jaw joint, where the specific location and details about the original injury are not documented.
Unspecified open wound of unspecified cheek and temporomandibular area, sequela.This code describes an open wound to the cheek and/or temporomandibular area that is not otherwise specified. The 7th character 'S' indicates that this is a sequela, meaning a late effect or condition resulting from a previous injury.
Example 1: A patient presents with chronic pain and limited jaw movement several months after a laceration to the cheek near the temporomandibular joint. The initial injury has healed, but the sequela requires ongoing management., A patient experiences persistent numbness in the cheek area years after a deep cut injury near the jaw. This ongoing sensory deficit, a sequela of the original injury, is documented with this code., A patient develops a recurrent infection at the site of a previous open wound on the cheek, now healed. This persistent issue, a late effect of the injury, is classified under this code.
Documentation should include details about the original injury, the current presenting symptoms related to the sequela, and any associated functional limitations.Details of physical examination findings, imaging results, and treatment provided for the sequela should also be recorded.
** This code specifically refers to the late effects of an open wound and should not be used to code the initial injury.Refer to iFrameAI product for the most accurate information and validation regarding NCCI edits and code pairing rules.
- Payment Status: Active
- Specialties:Emergency Medicine, Maxillofacial Surgery, Plastic Surgery, General Surgery
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital, Emergency Room - Hospital, Office,Outpatient Hospital