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ICD-10 Guide
ICD-10 CodesS21.11

S21.11

Billable

Laceration without foreign body of front wall of thorax without penetration into thoracic cavity

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

Code Description

ICD-10 S21.11 is a billable code used to indicate a diagnosis of laceration without foreign body of front wall of thorax without penetration into thoracic cavity.

Key Diagnostic Point:

S21.11 refers to a laceration of the front wall of the thorax that does not involve a foreign body and does not penetrate the thoracic cavity. This type of injury is often the result of blunt or penetrating trauma, such as from a fall, motor vehicle accident, or assault. Clinically, it is important to assess the extent of the laceration and any associated injuries, such as rib fractures, pneumothorax, or hemothorax. Rib fractures can occur due to the force of the injury, leading to potential complications like pneumothorax (air in the pleural space) or hemothorax (blood in the pleural space). Cardiac injuries may also be a concern, particularly in high-impact trauma cases. Surgical interventions may be necessary for severe lacerations or associated injuries, including thoracotomy for exploration and repair. Accurate coding of S21.11 requires careful documentation of the injury's nature, location, and any related complications, as well as the treatment provided.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between laceration types and associated injuries
  • Understanding the implications of rib fractures and their management
  • Identifying potential complications like pneumothorax and hemothorax
  • Documenting surgical interventions accurately

Audit Risk Factors

  • Inadequate documentation of injury severity
  • Failure to document associated injuries
  • Misclassification of laceration depth
  • Inconsistent coding of surgical interventions

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Detailed description of the mechanism of injury, assessment of vital signs, and any imaging studies performed.

Common Clinical Scenarios

Patients presenting with chest trauma from accidents, falls, or assaults.

Billing Considerations

Ensure documentation reflects the urgency of the situation and any immediate interventions performed.

Thoracic Surgery

Documentation Requirements

Comprehensive surgical notes detailing the procedure, findings, and any complications encountered.

Common Clinical Scenarios

Patients requiring surgical repair of thoracic wall lacerations or associated injuries.

Billing Considerations

Accurate coding of both the laceration and any surgical procedures performed is critical.

Coding Guidelines

Inclusion Criteria

Use S21.11 When
  • According to ICD
  • 10 guidelines, S21
  • 11 should be used when the laceration is documented as not involving a foreign body and not penetrating the thoracic cavity
  • Coders should ensure that the documentation supports the diagnosis and that any associated injuries are coded appropriately

Exclusion Criteria

Do NOT use S21.11 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used for laceration repair in the emergency department.

Documentation Requirements

Document the size, location, and depth of the laceration.

Specialty Considerations

Emergency medicine specialists should ensure that the repair is well-documented.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of thoracic injuries, improving the accuracy of data collection and reimbursement processes. S21.11 provides a clear distinction between types of lacerations, which aids in clinical management and research.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of thoracic injuries, improving the accuracy of data collection and reimbursement processes. S21.11 provides a clear distinction between types of lacerations, which aids in clinical management and research.

Reimbursement & Billing Impact

reimbursement processes. S21.11 provides a clear distinction between types of lacerations, which aids in clinical management and research.

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 S21.11 and S21.12?

S21.11 is used for lacerations without foreign bodies and without penetration into the thoracic cavity, while S21.12 is for lacerations that involve foreign bodies and penetrate the thoracic cavity.