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ICD-10 Guide
ICD-10 CodesS21.051

S21.051

Billable

Open bite of right breast

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/23/2025

Code Description

ICD-10 S21.051 is a billable code used to indicate a diagnosis of open bite of right breast.

Key Diagnostic Point:

An open bite of the right breast refers to a traumatic injury characterized by a break in the skin and underlying tissue, typically resulting from a bite wound. This injury can lead to significant complications, including infection, hematoma formation, and potential damage to underlying structures such as muscle and fat tissue. In cases of severe trauma, there may be associated injuries to the ribs, lungs, or even the heart, necessitating careful evaluation and management. The presence of an open wound increases the risk of contamination and infection, which can complicate healing and recovery. Treatment often involves thorough cleaning of the wound, possible surgical intervention to repair damaged tissues, and close monitoring for signs of infection or other complications. In the context of chest trauma, it is crucial to assess for rib fractures, pneumothorax, or hemothorax, as these conditions can arise from blunt or penetrating trauma to the thoracic region. Proper coding for an open bite of the right breast requires detailed documentation of the injury mechanism, associated injuries, and any surgical interventions performed.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Requires detailed documentation of the injury mechanism.
  • Potential for associated injuries complicating the coding.
  • Need for accurate differentiation from other types of breast injuries.
  • Involvement of multiple specialties for comprehensive care.

Audit Risk Factors

  • Inadequate documentation of the injury mechanism.
  • Failure to note associated injuries or complications.
  • Incorrect coding of the injury type (open vs. closed).
  • Lack of clarity in surgical intervention documentation.

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Detailed account of the injury mechanism, vital signs, and any immediate interventions.

Common Clinical Scenarios

Patients presenting with bite wounds from animals or humans, often with associated trauma.

Billing Considerations

Ensure thorough documentation of any potential complications such as pneumothorax or hemothorax.

General Surgery

Documentation Requirements

Surgical notes detailing the extent of the injury, repair techniques, and post-operative care.

Common Clinical Scenarios

Surgical intervention for severe bite wounds requiring debridement or reconstruction.

Billing Considerations

Document any additional procedures performed, such as drainage of hematomas or repair of underlying structures.

Coding Guidelines

Inclusion Criteria

Use S21.051 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the injury type, mechanism, and any associated injuries
  • Include details of surgical interventions if applicable

Exclusion Criteria

Do NOT use S21.051 When
  • Exclude codes for closed injuries or superficial wounds unless specified

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used for repair of the open bite wound.

Documentation Requirements

Document the size and depth of the wound, as well as the technique used.

Specialty Considerations

Ensure that the procedure is linked to the diagnosis of the open bite.

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 open bites, which improves the accuracy of patient records and facilitates better tracking of injury types and associated complications.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including open bites, which improves the accuracy of patient records and facilitates better tracking of injury types and associated complications.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of injuries, including open bites, which improves the accuracy of patient records and facilitates better tracking of injury types and associated complications.

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 bite and a closed bite?

An open bite involves a break in the skin and underlying tissue, while a closed bite does not penetrate the skin. Open bites are at higher risk for infection and complications.