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ICD-10 Guide
ICD-10 CodesS21.151

S21.151

Billable

Open bite of right front wall of thorax without penetration into thoracic cavity

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

Code Description

ICD-10 S21.151 is a billable code used to indicate a diagnosis of open bite of right front wall of thorax without penetration into thoracic cavity.

Key Diagnostic Point:

An open bite of the right front wall of the thorax refers to a traumatic injury where a portion of the thoracic wall is disrupted, typically due to a penetrating object or bite, but without breaching the thoracic cavity itself. This type of injury can lead to significant soft tissue damage, potential rib fractures, and complications such as pneumothorax or hemothorax if the injury is severe enough to affect the underlying structures. The absence of penetration into the thoracic cavity is crucial, as it differentiates this injury from more severe thoracic trauma that could involve lung or cardiac injuries. Patients may present with localized pain, swelling, and difficulty breathing, necessitating thorough evaluation and imaging to assess for associated injuries. Treatment may involve wound care, pain management, and monitoring for complications, with surgical intervention considered if there are significant soft tissue injuries or if the injury evolves to involve deeper structures.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiation from similar codes related to thoracic injuries.
  • Need for precise documentation of the injury mechanism.
  • Assessment of associated injuries such as rib fractures or pneumothorax.
  • Potential for complications requiring additional coding.

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury.
  • Failure to note associated injuries.
  • Misclassification of the injury type.
  • Lack of follow-up documentation on treatment outcomes.

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 trauma from bites or accidents leading to chest wall injuries.

Billing Considerations

Ensure thorough documentation of any associated injuries and treatment plans.

Thoracic Surgery

Documentation Requirements

Comprehensive surgical notes detailing the extent of the injury and any interventions performed.

Common Clinical Scenarios

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

Billing Considerations

Accurate coding of surgical procedures related to the injury is essential.

Coding Guidelines

Inclusion Criteria

Use S21.151 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the code is used only when there is clear documentation of an open bite injury to the thorax without penetration

Exclusion Criteria

Do NOT use S21.151 When
  • Exclude codes for closed injuries or those with complications unless they are documented

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used for wound closure after an open bite injury.

Documentation Requirements

Document the size and depth of the wound, as well as the method of closure.

Specialty Considerations

Emergency medicine and surgical specialties should ensure accurate coding of the repair.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of injuries like S21.151, improving the accuracy of data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries like S21.151, improving the accuracy of data collection and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

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 injury?

An open bite involves a break in the skin and exposure of underlying tissues, while a closed injury does not breach the skin and may involve internal structures without external wounds.