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ICD-10 Guide
ICD-10 CodesS11.10

S11.10

Billable

Unspecified open wound of thyroid gland

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

Code Description

ICD-10 S11.10 is a billable code used to indicate a diagnosis of unspecified open wound of thyroid gland.

Key Diagnostic Point:

An unspecified open wound of the thyroid gland refers to a traumatic injury that results in a break in the skin and underlying tissues of the thyroid gland, which is located in the anterior neck. This type of injury can occur due to various mechanisms, including penetrating trauma from sharp objects, blunt force trauma, or surgical complications. The thyroid gland plays a crucial role in regulating metabolism and hormonal balance, and injuries to this area can lead to significant complications, including hemorrhage, infection, and potential damage to surrounding structures such as the trachea and esophagus. Clinical evaluation typically involves a thorough physical examination, imaging studies such as ultrasound or CT scans, and laboratory tests to assess thyroid function. Management may include wound care, surgical intervention to repair the wound, and monitoring for complications. Accurate coding is essential for proper reimbursement and tracking of healthcare outcomes.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation of the type and extent of the wound
  • Need for precise anatomical terminology
  • Potential for associated injuries requiring additional codes
  • Differentiation between open and closed wounds

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to specify the type of open wound
  • Lack of follow-up documentation on treatment and outcomes
  • Inconsistent coding of associated injuries

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Documentation must include details of the mechanism of injury, initial assessment findings, and any immediate interventions performed.

Common Clinical Scenarios

Patients presenting with stab wounds or lacerations to the neck area, often requiring urgent evaluation and management.

Billing Considerations

Ensure that all relevant injuries are documented, including potential airway compromise.

Surgery

Documentation Requirements

Operative reports must detail the surgical approach, findings, and any complications encountered during the procedure.

Common Clinical Scenarios

Surgical repair of thyroid injuries following trauma or during thyroidectomy procedures.

Billing Considerations

Document any additional procedures performed, such as hemostasis or drainage of hematomas.

Coding Guidelines

Inclusion Criteria

Use S11.10 When
  • Follow ICD
  • CM guidelines for coding injuries, ensuring specificity and accuracy in documenting the nature of the wound and any associated injuries

Exclusion Criteria

Do NOT use S11.10 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

60240CPT Code

Thyroidectomy, total or subtotal

Clinical Scenario

Used when a patient undergoes surgery for an open wound of the thyroid gland.

Documentation Requirements

Operative report must detail the procedure and any complications.

Specialty Considerations

Surgeons should document the extent of the injury and any additional procedures performed.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 allows for more specific coding of injuries, which can improve data accuracy and facilitate better patient care management.

ICD-9 vs ICD-10

The transition to ICD-10 allows for more specific coding of injuries, which can improve data accuracy and facilitate better patient care management.

Reimbursement & Billing Impact

The transition to ICD-10 allows for more specific coding of injuries, which can improve data accuracy and facilitate better patient care management.

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 S11.10 and S11.11?

S11.10 is used for unspecified open wounds of the thyroid gland, while S11.11 specifies an open wound of the isthmus of the thyroid gland.