2025 ICD-10-CM code S61.102D
Unspecified open wound of left thumb with damage to the nail, subsequent encounter.
Medical necessity is established by the presence of an open wound on the left thumb with associated nail damage requiring medical evaluation and treatment.
Providers diagnose the condition based on the patient’s history and physical examination, particularly to assess the nerves, bones, and blood vessels, depending on the depth and severity of the wound, and imaging techniques such as X–rays to determine the extent of damage and to evaluate for foreign bodies. Treatment options include control of any bleeding; immediate thorough cleaning of the wound, surgical removal of damaged or infected tissue, and repair of the wound; application of appropriate topical medication and dressing; and analgesics and nonsteroidal antiinflammatory drugs for pain; antibiotics to prevent or treat an infection, and tetanus prophylaxis.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the wrist, hand and fingers (S60-S69)
In simple words: An unspecified open wound of the left thumb with damage to the nail refers to injuries such as cuts, punctures, or bites to the thumb that break the skin, exposing the tissue underneath and involving the nail. The doctor hasn't specified what kind of open wound it is during this visit, which isn't the first one for this injury.
An unspecified open wound of the left thumb with damage to the nail refers to injuries such as lacerations, puncture wounds, or open bites of the thumb which break the skin and expose the underlying tissues to the air, with involvement of the nail. The provider does not specify the nature of the open wound of the left thumb at this subsequent encounter for the injury.
Example 1: A patient presents for a follow-up visit after lacerating their left thumb and damaging the nail while using a kitchen knife. The wound is healing, but the patient still has some pain and swelling., A patient was previously treated for an open bite to the left thumb that resulted in nail damage. They return for a follow-up appointment to monitor for infection and ensure proper healing., A patient sustained a puncture wound to their left thumb with nail involvement while working in the garden. They initially received treatment at an urgent care center and are now seeing their primary care physician for a follow-up evaluation.
Documentation should include the nature of the injury (laceration, puncture, bite, etc.), the extent of the damage to the nail, the presence of any foreign bodies, the location of the wound on the left thumb, and the treatment provided.
- Specialties:Emergency Medicine, Family Medicine, General Surgery, Hand Surgery, Orthopedic Surgery, Urgent Care
- Place of Service:Office, Home, Inpatient Hospital, On Campus-Outpatient Hospital, Emergency Room - Hospital, Urgent Care Facility, Outpatient Hospital, Independent Clinic, Federally Qualified Health Center