ICD-10 Guide

S91

Non-billable

Open wound of ankle, foot and toes

Chapter 19:Injury, poisoning and other consequences of external causes

BILLABLE STATUSNo

IMPLEMENTATION DATEOctober 1, 2015

LAST UPDATED09/05/2025

Code Description

ICD-10 S91 is a used to indicate a diagnosis of open wound of ankle, foot and toes.

Key Diagnostic Point:

The ICD-10 Level 1 Category code S91 pertains to open wounds of the ankle, foot, and toes. This category encompasses a variety of conditions that result from trauma, including lacerations, abrasions, and puncture wounds. These injuries can range from minor to severe, potentially affecting the skin, underlying tissues, and even bones. The clinical significance of accurately coding S91 lies in the necessity for appropriate treatment plans, which may include wound care, surgical intervention, or referral to specialists, depending on the severity and complexity of the injury. Proper coding ensures that healthcare providers can effectively communicate the nature of the injury and the required management strategies to insurance companies and other stakeholders.

Usage guidelines for S91 codes recommend that healthcare providers document the specific type and location of the wound, as well as any associated complications such as infections or foreign body presence. Accurate documentation is crucial for coding purposes and for ensuring that patients receive the appropriate level of care. Additionally, understanding the nuances of this category can help prevent coding errors that may lead to claim denials or delays in reimbursement, ultimately impacting patient care and healthcare operations.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

Variety of wound types
Potential for complications
Need for precise documentation

Audit Risk Factors

Inadequate documentation
Misclassification of wound severity
Failure to capture associated complications

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Standard ICD-10-CM documentation requirements apply

Common Clinical Scenarios

Various clinical presentations within this specialty area

Billing Considerations

Follow specialty-specific billing guidelines

Orthopedic Surgery

Documentation Requirements

Standard ICD-10-CM documentation requirements apply

Common Clinical Scenarios

Various clinical presentations within this specialty area

Billing Considerations

Follow specialty-specific billing guidelines

Related CPT Codes

CPT Code

Clinical Scenario

Documentation Requirements

CPT Code

Clinical Scenario

Documentation Requirements

CPT Code

Clinical Scenario

Documentation Requirements

CPT Code

Clinical Scenario

Documentation Requirements

CPT Code

Clinical Scenario

Documentation Requirements

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

From an administrative perspective, the S91 category plays a crucial role in healthcare data analytics and resource allocation. By analyzing the frequency and types of open wounds treated, healthcare organizations can identify patterns that may indicate the need for targeted interventions or community health initiatives. This data can also inform policy decisions and contribute to population health strategies aimed at reducing the incidence of such injuries.

ICD-9 vs ICD-10

The clinical impact of the S91 code category is significant, as it directly relates to the management of open wounds, which can lead to complications such as infections or delayed healing if not treated properly. Accurate coding can influence quality measures and patient outcomes, as it allows for better tracking of wound care and associated complications in patient populations. Furthermore, understanding trends in open wound injuries can help healthcare providers implement preventive measures and improve overall patient care. From an administrative perspective, the S91 category plays a crucial role in healthcare data analytics and resource allocation. By analyzing the frequency and types of open wounds treated, healthcare organizations can identify patterns that may indicate the need for targeted interventions or community health initiatives. This data can also inform policy decisions and contribute to population health strategies aimed at reducing the incidence of such injuries.

Reimbursement & Billing Impact

Reimbursement considerations may vary based on the complexity of the wound and the interventions performed, which can include wound debridement, suturing, or other surgical procedures. It is essential to document all aspects of care thoroughly to support the billing process and to justify the medical necessity of the services provided.

Resources

Clinical References

•
Official ICD-10 Guidelines for S91

Coding & Billing References

•
Official ICD-10 Guidelines for S91

Frequently Asked Questions

What conditions are included in S91?

S91 includes various types of open wounds such as lacerations, abrasions, puncture wounds, and avulsions affecting the ankle, foot, and toes.

When should I use S91 codes?

S91 codes should be used when documenting open wounds of the ankle, foot, or toes, particularly when these injuries require specific treatment or management.

What documentation is required for S91?

Documentation should include the type of wound, location, size, depth, any associated complications, and the treatment provided.

ICD-10 S91 is a used to indicate a diagnosis of open wound of ankle, foot and toes.

Key Diagnostic Point:

Usage guidelines for S91 codes recommend that healthcare providers document the specific type and location of the wound, as well as any associated complications such as infections or foreign body presence. Accurate documentation is crucial for coding purposes and for ensuring that patients receive the appropriate level of care. Additionally, understanding the nuances of this category can help prevent coding errors that may lead to claim denials or delays in reimbursement, ultimately impacting patient care and healthcare operations.