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ICD-10 Guide
ICD-10 CodesS21.139

S21.139

Billable

Puncture wound without foreign body of unspecified front wall of thorax without penetration into thoracic cavity

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

Code Description

ICD-10 S21.139 is a billable code used to indicate a diagnosis of puncture wound without foreign body of unspecified front wall of thorax without penetration into thoracic cavity.

Key Diagnostic Point:

S21.139 refers to a puncture wound located on the front wall of the thorax that does not involve a foreign body and does not penetrate the thoracic cavity. Such injuries can occur due to various incidents, including accidents or assaults. Clinically, these wounds may present with localized pain, swelling, and potential bruising. Although the injury does not penetrate the thoracic cavity, it is essential to monitor for complications such as pneumothorax or hemothorax, which can arise from associated rib fractures or blunt trauma. The absence of a foreign body simplifies the management of the wound, focusing on cleaning, suturing if necessary, and monitoring for signs of infection or other complications. Proper assessment and documentation are crucial to ensure appropriate coding and treatment planning.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between types of thoracic injuries
  • Assessing for associated rib fractures or internal injuries
  • Understanding the implications of non-penetrating versus penetrating wounds
  • Documentation of the mechanism of injury

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to assess for associated rib fractures
  • Misclassification of the wound type
  • Omission of follow-up care details

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Detailed account of the injury mechanism, physical examination findings, and any imaging results.

Common Clinical Scenarios

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

Billing Considerations

Ensure thorough documentation of any potential complications and follow-up care.

Trauma Surgery

Documentation Requirements

Comprehensive surgical notes detailing the injury, treatment provided, and any surgical interventions.

Common Clinical Scenarios

Management of chest trauma requiring surgical intervention or observation for complications.

Billing Considerations

Accurate coding of associated injuries and surgical procedures is critical.

Coding Guidelines

Inclusion Criteria

Use S21.139 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the injury type, location, and any associated complications

Exclusion Criteria

Do NOT use S21.139 When
  • Exclude codes for penetrating wounds or those with foreign bodies

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used for the repair of the puncture wound if suturing is required.

Documentation Requirements

Document the size of the wound and the method of repair.

Specialty Considerations

Emergency medicine and trauma surgery may have specific protocols for wound management.

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 puncture wounds, which enhances the accuracy of patient records and billing.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including puncture wounds, which enhances the accuracy of patient records and billing.

Reimbursement & Billing Impact

billing.

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 a puncture wound and a laceration?

A puncture wound is a small hole caused by a sharp object, while a laceration is a tear or cut in the skin that may be deeper and wider.