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ICD-10 Guide
ICD-10 CodesS21.10

S21.10

Billable

Unspecified open wound of front wall of thorax without penetration into thoracic cavity

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

Code Description

ICD-10 S21.10 is a billable code used to indicate a diagnosis of unspecified open wound of front wall of thorax without penetration into thoracic cavity.

Key Diagnostic Point:

An unspecified open wound of the front wall of the thorax refers to a traumatic injury that results in a break in the skin and underlying tissues of the chest wall, without any penetration into the thoracic cavity. This type of injury can occur due to various mechanisms, including blunt trauma, penetrating trauma, or surgical interventions. The front wall of the thorax includes the sternum and ribs, and injuries in this area can lead to complications such as rib fractures, pneumothorax, hemothorax, and potential cardiac injuries. While the wound may not penetrate the thoracic cavity, it can still cause significant pain, respiratory distress, and may require surgical intervention for repair or management of associated injuries. Accurate coding is essential for proper treatment planning and reimbursement, as well as for tracking the incidence of chest trauma in clinical settings.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation of wound specifics (size, depth, location)
  • Potential for associated injuries (e.g., rib fractures, pneumothorax)
  • Differentiation from other thoracic injuries (e.g., penetrating wounds)
  • Need for precise clinical terminology to avoid misclassification

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to document associated injuries or complications
  • Misclassification of wound type (open vs. closed)
  • Inconsistent use of terminology in clinical notes

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Detailed description of the injury mechanism, assessment of associated injuries, and treatment provided.

Common Clinical Scenarios

Patients presenting with chest trauma from motor vehicle accidents, falls, or sports injuries.

Billing Considerations

Ensure thorough documentation of vital signs and any imaging studies performed to assess for complications.

Thoracic Surgery

Documentation Requirements

Operative reports detailing the nature of the wound, surgical interventions performed, and any complications encountered.

Common Clinical Scenarios

Surgical repair of chest wall defects or management of complications from chest trauma.

Billing Considerations

Accurate coding of any additional procedures performed during surgery is crucial for proper billing.

Coding Guidelines

Inclusion Criteria

Use S21.10 When
  • According to ICD
  • 10 coding guidelines, this code should be used when the documentation specifies an open wound of the thorax without penetration
  • It is important to ensure that the documentation supports the diagnosis and that any associated injuries are coded separately

Exclusion Criteria

Do NOT use S21.10 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used for repair of the open wound on the chest wall.

Documentation Requirements

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

Specialty Considerations

Ensure that the procedure is documented in the context of the injury.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of chest injuries, improving the ability to track and manage trauma cases. S21.10 provides a clear designation for open wounds without penetration, facilitating better clinical management and reimbursement.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of chest injuries, improving the ability to track and manage trauma cases. S21.10 provides a clear designation for open wounds without penetration, facilitating better clinical management and reimbursement.

Reimbursement & Billing Impact

reimbursement.

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 S21.10 and S21.11?

S21.10 is used for open wounds without penetration into the thoracic cavity, while S21.11 is for wounds that do penetrate the thoracic cavity, which may involve more serious complications.