Open wound of vocal cord
ICD-10 S11.03 is a billable code used to indicate a diagnosis of open wound of vocal cord.
An open wound of the vocal cord refers to a laceration or tear affecting the vocal folds, which are critical for phonation and airway protection. This injury can occur due to various mechanisms, including trauma from blunt or penetrating injuries, surgical procedures, or thermal and chemical burns. The vocal cords are delicate structures located in the larynx, and any injury can lead to significant complications such as hoarseness, loss of voice, or airway obstruction. Diagnosis typically involves a thorough history and physical examination, often supplemented by laryngoscopy to visualize the extent of the injury. Management may include conservative measures such as voice rest and hydration, or surgical intervention to repair the wound, depending on the severity. Complications can include scarring, chronic dysphonia, or aspiration pneumonia if airway protection is compromised. Accurate coding is essential for proper reimbursement and tracking of outcomes related to vocal cord injuries.
Documentation must include the mechanism of injury, initial assessment findings, and any immediate interventions performed.
Trauma cases involving blunt force to the neck or penetrating injuries from foreign objects.
Consideration of airway management and potential need for intubation in severe cases.
Operative reports should detail the surgical approach, findings, and any repairs made to the vocal cords.
Surgical interventions for vocal cord repair following trauma or during laryngeal surgeries.
Documentation must clearly indicate the surgical technique used and any complications encountered.
Used to assess vocal cord injuries in emergency settings.
Document findings from the laryngoscopy and any interventions performed.
Emergency medicine specialists should ensure thorough documentation of the injury mechanism.
Used when a biopsy is needed during the assessment of vocal cord injuries.
Document the indication for biopsy and findings.
Surgeons must document the rationale for biopsy and any complications.
The primary mechanisms include blunt trauma, penetrating injuries, thermal burns, and surgical complications.
Accurate coding requires detailed documentation of the injury type, mechanism, and any associated complications. Always specify whether the wound is open or closed.
