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2025 ICD-10-CM code S81.0

Open wound of the knee.

Follow official ICD-10-CM coding guidelines for proper selection and sequencing of codes.Always use the most specific code available to accurately reflect the patient's condition.Use additional codes to specify the cause of injury (Chapter 20) and any complications (e.g., infection).

Modifiers are not applicable to ICD-10 codes.

Medical necessity is established when the open wound requires professional medical intervention such as wound cleaning, repair, or management of complications like infection. Documentation supporting the need for these services must be provided. The severity and location of the wound justify the level of intervention.

The clinical responsibility includes diagnosis and treatment of the open knee wound. This may involve wound care, surgical repair, pain management, infection prevention, and monitoring for complications.The provider's role may also include ordering and interpreting imaging studies, and ensuring appropriate follow-up care.

IMPORTANT:Use additional code Z18.- for retained foreign body, if applicable.Secondary codes from Chapter 20 (External causes of morbidity) should be used to indicate the cause of injury, unless the external cause is already included within the T-section codes.Excludes: birth trauma (P10-P15), obstetric trauma (O70-O71), burns and corrosions (T20-T32), frostbite (T33-T34), injuries of ankle and foot (except fracture of ankle and malleolus) (S90-S99), insect bite or sting, venomous (T63.4), open fracture of knee and lower leg (S82.-), traumatic amputation of lower leg (S88.-), open wound of ankle and foot (S91.-).

In simple words: This code describes an open wound, like a cut or puncture, on the knee. It can cause pain, bleeding, swelling, and infection. Doctors diagnose it by examining the knee and may use X-rays. Treatment might involve cleaning the wound, stitches, medicine for pain and infection, and a tetanus shot.

An open wound of the knee refers to injuries such as lacerations, puncture wounds, or open bites of the knee that break the skin and expose underlying tissues.Potential complications include pain, bleeding, tenderness, swelling, bruising, infection, inflammation, restricted motion, and numbness or tingling due to nerve or blood vessel damage. Diagnosis involves patient history, physical examination (assessing nerves, bones, and blood vessels), and imaging (e.g., X-rays) to determine the extent of damage and identify foreign bodies. Treatment may include bleeding control, wound cleaning, surgical debridement and repair, topical medication and dressings, analgesics, anti-inflammatory drugs, antibiotics (to prevent or treat infection), and tetanus vaccination.

Example 1: A patient presents to the emergency room after a fall, sustaining a deep laceration to their knee requiring sutures., A patient is seen in a clinic setting for a superficial abrasion to the knee sustained while playing sports. The wound is cleaned and dressed., A patient sustains a puncture wound to their knee from stepping on a nail. They require cleaning, debridement, and antibiotic treatment to prevent infection.

Complete documentation should include a detailed description of the wound (location, size, depth, type), mechanism of injury, assessment of surrounding structures (nerves, vessels, bones), treatment provided (wound cleansing, debridement, repair, dressings, medications), and any complications or follow-up plans.

** The seventh character (A, D, or S) should be added to specify the encounter (initial, subsequent, or sequela).

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