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2025 ICD-10-CM code S21

Open wound of the thorax; this code encompasses injuries to the chest wall, breast, and may include associated injuries to internal organs.

Refer to the official ICD-10-CM coding guidelines for detailed instructions.

Modifiers may apply depending on the circumstances of the encounter. Consult the official coding guidelines and payer specific instructions.

The medical necessity for treatment of an open wound of the thorax is based on the need to prevent infection, control bleeding, repair the wound, and alleviate pain. Documentation should support the extent of injury requiring the level of treatment received.

Diagnosis is based on patient history, physical examination, and potentially imaging studies (X-rays). Treatment involves wound management (hemostasis, cleaning, debridement, repair), dressing, analgesics, antibiotics, tetanus prophylaxis, and anti-inflammatory medications.

IMPORTANT:Code also any associated injury, such as: injury of heart (S26.-), injury of intrathoracic organs (S27.-), rib fracture (S22.3-, S22.4-), spinal cord injury (S24.0-, S24.1-), traumatic hemopneumothorax (S27.3), traumatic hemothorax (S27.1), traumatic pneumothorax (S27.0), wound infection.Excludes1: traumatic amputation (partial) of thorax (S28.1).

In simple words: An open wound on the chest, which can involve the skin, ribs, or other parts of the chest area.Other injuries, like damage to the heart or lungs, would be coded separately.

S21, Open wound of thorax, in the ICD-10-CM classification system, represents an open wound affecting the chest region.This includes injuries to the chest wall, breast, and potentially underlying structures.Associated injuries, such as injury to the heart (S26.-), intrathoracic organs (S27.-), rib fractures (S22.3-, S22.4-), spinal cord injury (S24.0-, S24.1-), traumatic hemopneumothorax (S27.3), traumatic hemothorax (S27.1), traumatic pneumothorax (S27.0), or wound infection, should be coded separately.Traumatic amputation (partial) of the thorax (S28.1) is excluded from this code. The seventh character (A, D, S) specifies the encounter (initial, subsequent, or sequela).

Example 1: A patient presents to the emergency department after a motor vehicle accident with a laceration to the right anterior chest wall. The wound is superficial and does not penetrate the pleural space.The appropriate code would be S21.101 (Unspecified open wound of right front wall of thorax without penetration into thoracic cavity), with additional codes for any other injuries., A patient sustains a deep penetrating wound to the left chest, resulting in a pneumothorax and rib fractures. The codes would include S21.4 (Open wound of back wall of thorax with penetration into thoracic cavity) along with S27.0 (Traumatic pneumothorax) and S22.4- (rib fracture codes)., A patient receives a stab wound to the breast resulting in a laceration with a retained foreign body. In addition to the S21 code, a code from category Z18.- (Foreign body) should be added.

Detailed description of the wound (location, size, depth, and presence of foreign bodies), mechanism of injury, physical examination findings, imaging results (if performed), and treatment provided (debridement, closure, antibiotics, etc.).

** S21 is a parent code.More specific codes within the S21 range should be used when possible to improve coding accuracy and reimbursement.

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