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2025 ICD-10-CM code S81.8

Open wound of lower leg.

Use secondary code(s) from Chapter 20 (External causes of morbidity) to indicate the cause of injury.Use additional code to identify any retained foreign body, if applicable (Z18.-).

Medical necessity is established by the presence of an open wound requiring medical intervention for cleaning, repair, or infection prevention.

Providers diagnose the condition based on the patient’s history and physical examination, especially assessing nerves, bones, and blood vessels depending on wound depth and severity. Imaging techniques like X-rays determine the extent of damage and evaluate for foreign bodies. Treatment options include controlling bleeding, immediate wound cleaning, surgical removal of damaged tissue, wound repair, topical medication, dressings, analgesics, anti-inflammatory drugs for pain, antibiotics for infection prevention/treatment, tetanus prophylaxis, and rabies treatment if necessary.

In simple words: An open wound on your lower leg, like a cut, puncture, or bite, that breaks the skin.

An open wound of the lower leg refers to injuries such as lacerations, puncture wounds, or open bites, which break the skin and expose the underlying tissues. This can result in pain, bleeding, tenderness, stiffness, swelling, bruising, infection, inflammation, restricted motion, and numbness and tingling due to possible injury to nerves and blood vessels.

Example 1: A patient presents with a deep laceration on their lower leg after falling on a sharp rock. The wound is cleaned, sutured, and dressed. The patient receives a tetanus booster., A child is bitten by a dog on the lower leg, resulting in a puncture wound. The wound is cleaned and dressed, and the child receives antibiotics and rabies prophylaxis., An elderly patient with diabetes develops a non-healing ulcer on their lower leg. The wound is debrided and treated with topical medications and dressings.

Documentation should include the cause, nature, and location of the wound; the size and depth of the injury; any associated symptoms; treatment provided; and the presence of any foreign bodies.

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