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ICD-10 Guide
ICD-10 CodesS11.039

S11.039

Billable

Unspecified open wound of vocal cord

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 S11.039 is a billable code used to indicate a diagnosis of unspecified open wound of vocal cord.

Key Diagnostic Point:

An unspecified open wound of the vocal cord refers to a traumatic injury that disrupts the integrity of the vocal cord tissue, which may occur due to various mechanisms such as blunt or penetrating trauma, thermal injury, or chemical exposure. The vocal cords, located in the larynx, are essential for phonation and airway protection. Open wounds can lead to significant complications, including infection, scarring, and voice changes. The clinical presentation may include hoarseness, stridor, or respiratory distress, depending on the severity of the injury. Diagnosis typically involves laryngoscopy to visualize the vocal cords and assess the extent of the injury. Management may include supportive care, voice rest, and in some cases, surgical intervention to repair the wound or address complications. The prognosis varies based on the injury's severity and the timeliness of treatment.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in injury mechanisms leading to open wounds
  • Potential for associated injuries in the laryngeal area
  • Need for precise documentation of the injury's nature and cause
  • Differentiation from other laryngeal injuries or conditions

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to specify the extent of the wound
  • Misclassification of the injury type
  • Lack of follow-up documentation on treatment outcomes

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Documentation should include a detailed account of the mechanism of injury, initial assessment findings, and any immediate interventions performed.

Common Clinical Scenarios

Trauma patients presenting with laryngeal injuries from accidents, assaults, or foreign body ingestion.

Billing Considerations

Ensure that all relevant details about the injury and patient history are captured to support the coding.

Surgery

Documentation Requirements

Operative reports must detail the surgical approach, findings, and any repairs made to the vocal cords.

Common Clinical Scenarios

Surgical intervention for vocal cord repair following trauma or thermal injury.

Billing Considerations

Document any complications or additional procedures performed during surgery.

Coding Guidelines

Inclusion Criteria

Use S11.039 When
  • Follow the official ICD
  • CM coding guidelines for injuries, ensuring that the code reflects the specific nature of the injury and any associated conditions

Exclusion Criteria

Do NOT use S11.039 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

31505CPT Code

Laryngoscopy, flexible, diagnostic

Clinical Scenario

Used to evaluate vocal cord injuries in emergency settings.

Documentation Requirements

Document indications for the procedure and findings.

Specialty Considerations

Emergency medicine and ENT specialists should ensure accurate coding based on findings.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of injuries, including those of the vocal cords, which aids in better tracking and management of such injuries.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including those of the vocal cords, which aids in better tracking and management of such injuries.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of injuries, including those of the vocal cords, which aids in better tracking and management of such injuries.

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 an open wound and a closed wound of the vocal cord?

An open wound involves a break in the skin or mucosal surface, exposing underlying tissues, while a closed wound does not disrupt the surface integrity.