Laceration without foreign body of scalp
ICD-10 S01.01 is a billable code used to indicate a diagnosis of laceration without foreign body of scalp.
S01.01 refers to a laceration of the scalp that does not involve any foreign body. This type of injury is typically caused by blunt or sharp trauma, such as falls, sports injuries, or accidents involving sharp objects. The scalp is highly vascularized, which can lead to significant bleeding even with minor lacerations. Clinically, these injuries may present with pain, swelling, and visible cuts or tears in the scalp tissue. Diagnosis is primarily based on physical examination, where the depth, length, and location of the laceration are assessed. Imaging studies are rarely necessary unless there is suspicion of underlying skull injury. Management usually involves cleaning the wound, controlling bleeding, and suturing if necessary. Complications can include infection, scarring, and in rare cases, damage to underlying structures. Accurate coding requires thorough documentation of the injury mechanism, treatment provided, and any complications encountered during care.
Documentation should include the mechanism of injury, vital signs, and initial assessment findings.
Trauma from falls, sports injuries, or accidents leading to scalp lacerations.
Ensure that all relevant details of the injury and treatment are documented to support coding.
Operative reports must detail the procedure performed, including any suturing techniques and post-operative care.
Surgical repair of scalp lacerations requiring sutures or staples.
Document any complications or additional procedures performed during surgery.
Used when a simple laceration repair is performed in the ER.
Document the size of the laceration and the repair technique used.
Emergency medicine providers should ensure that all details of the injury and repair are documented.
S01.01 is used for lacerations of the scalp without foreign bodies, while S01.00 is for lacerations with foreign bodies present. Accurate documentation is essential to determine the correct code.
