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ICD-10 Guide
ICD-10 CodesS71.111

S71.111

Billable

Laceration without foreign body, right thigh

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/25/2025

Code Description

ICD-10 S71.111 is a billable code used to indicate a diagnosis of laceration without foreign body, right thigh.

Key Diagnostic Point:

S71.111 refers to a laceration of the right thigh that does not involve any foreign body. This type of injury is typically caused by sharp objects or trauma, leading to a break in the skin and underlying tissues. The thigh is a significant area of the body, housing major muscles, blood vessels, and nerves. Lacerations in this region can vary in severity, from superficial cuts to deep wounds that may involve muscle or even bone. Proper assessment and management are crucial to prevent complications such as infection, excessive bleeding, or damage to surrounding structures. In cases where the laceration is extensive, surgical intervention may be necessary to repair the tissue and ensure proper healing. The management of such injuries often involves cleaning the wound, suturing if required, and monitoring for signs of infection. Understanding the anatomy of the thigh and the potential implications of a laceration in this area is essential for effective treatment and coding.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in injury severity and treatment options
  • Need for precise documentation of wound characteristics
  • Potential for associated injuries (e.g., muscle or nerve damage)
  • Differentiation from other types of thigh injuries (e.g., fractures, dislocations)

Audit Risk Factors

  • Inadequate documentation of the injury's extent
  • Failure to specify the mechanism of injury
  • Misclassification of the injury type (e.g., coding a laceration as a fracture)
  • Lack of follow-up documentation on healing or complications

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed descriptions of the laceration, including depth, length, and any associated injuries.

Common Clinical Scenarios

Lacerations resulting from sports injuries, falls, or accidents requiring surgical intervention.

Billing Considerations

Ensure that all associated injuries are documented to avoid undercoding.

Emergency Medicine

Documentation Requirements

Immediate assessment notes, including vital signs and initial treatment provided.

Common Clinical Scenarios

Patients presenting with acute lacerations from trauma or accidents.

Billing Considerations

Timely documentation is critical for accurate coding and billing.

Coding Guidelines

Inclusion Criteria

Use S71.111 When
  • According to ICD
  • 10 guidelines, S71
  • 111 should be used when documenting a laceration without foreign body involvement
  • It is important to specify the location and nature of the injury

Exclusion Criteria

Do NOT use S71.111 When
  • Exclusions include lacerations with foreign bodies or those that are part of a more complex injury requiring different coding

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used when a laceration requires simple closure without complications.

Documentation Requirements

Document the size and location of the laceration, as well as the method of closure.

Specialty Considerations

Orthopedic surgeons may need to document any additional procedures performed.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of lacerations, improving the accuracy of medical records and billing. S71.111 provides a clear distinction for lacerations without foreign bodies, which aids in treatment planning and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of lacerations, improving the accuracy of medical records and billing. S71.111 provides a clear distinction for lacerations without foreign bodies, which aids in treatment planning and resource allocation.

Reimbursement & Billing Impact

billing. S71.111 provides a clear distinction for lacerations without foreign bodies, which aids in treatment planning and resource allocation.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What is the difference between S71.111 and S71.112?

S71.111 is used for lacerations without foreign bodies, while S71.112 is for lacerations that involve foreign materials. Accurate documentation is essential to determine the correct code.