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2025 ICD-10-CM code S01.95

Open bite wound of unspecified part of the head.

Appropriate secondary codes from Chapter 20 should be used to specify the external cause of the injury, unless the external cause is already included in the T-section code.Always code any retained foreign body using the appropriate Z18.- code.

Modifiers may be applicable depending on the circumstances of the encounter (e.g., multiple wounds, different providers involved). Consult the appropriate modifier guidelines for further clarification.

Medical necessity is established by the presence of an open wound requiring treatment to prevent infection, control bleeding, and promote healing.The severity of the wound, presence of complications, and the need for surgical intervention would all influence the medical necessity determination.

The clinical responsibility includes diagnosing the condition through patient history and physical examination, assessing the wound, nerve, and blood supply. Treatment involves wound care (controlling bleeding, cleaning, debridement, and repair), administering medications (analgesics, antibiotics, tetanus prophylaxis, and NSAIDs), and applying appropriate dressings.

IMPORTANT:Use additional code to identify any retained foreign body (Z18.-).Secondary codes from Chapter 20 (External causes of morbidity) should be used to indicate the cause of injury, unless the T-section code already includes the external cause. Excludes superficial bite of head NOS (S00.97).

In simple words: This code describes an open wound on the head caused by a bite (animal or human). The exact location of the bite on the head is unknown.Treatment may include cleaning the wound, stitches, pain relievers, and antibiotics.

An open bite wound of an unspecified part of the head refers to an injury to the affected area and its associated structures resulting from a bite by an animal or human. The location of the head injury is not specified by the provider.This injury may cause pain, swelling, bruising, bleeding, deformity, and soft tissue infection. Diagnosis is based on patient history and physical examination to assess the wound, nerve, and blood supply. Treatment involves controlling bleeding, wound cleaning and debridement (removal of damaged tissue and foreign bodies), wound repair, application of topical medication and dressings, and analgesics, antibiotics, tetanus prophylaxis, and NSAIDs.

Example 1: A child is bitten on the face by a dog, resulting in a laceration requiring sutures. The exact location of the bite on the face is not specified in the medical record., An adult is involved in an altercation and sustains a bite wound to the head; the precise location of the injury is unknown., A patient presents with a deep bite wound to the scalp, with embedded debris requiring debridement and further wound management.

Detailed description of the wound (size, depth, location if known), presence of foreign bodies, treatment rendered (including type of suture material, if any), and any complications.

** This code is used when the specific location of the bite wound on the head cannot be determined.Always ensure that the documentation supports the level of service provided.

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

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