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ICD-10 Guide
ICD-10 CodesS21.152

S21.152

Billable

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

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

Code Description

ICD-10 S21.152 is a billable code used to indicate a diagnosis of open bite of left front wall of thorax without penetration into thoracic cavity.

Key Diagnostic Point:

An open bite of the left front wall of the thorax refers to a traumatic injury characterized by a laceration or puncture wound that does not penetrate the thoracic cavity. This type of injury can occur due to various mechanisms, including animal bites, sharp objects, or blunt force trauma that results in skin and soft tissue damage. Clinically, it is essential to assess the injury for potential complications such as rib fractures, pneumothorax, or hemothorax, which may arise from associated blunt trauma. Although the injury is classified as 'without penetration into the thoracic cavity,' careful evaluation is necessary to rule out underlying thoracic injuries, particularly in cases of significant trauma. Treatment typically involves wound care, possible surgical intervention for extensive tissue damage, and monitoring for complications. Accurate coding is crucial for appropriate management and reimbursement, as well as for tracking injury patterns in trauma registries.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between open and closed injuries
  • Assessing for associated rib fractures or pneumothorax
  • Documenting the mechanism of injury accurately
  • Determining the need for surgical intervention

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to assess for associated thoracic injuries
  • Misclassification of the injury type (open vs. closed)
  • Lack of follow-up documentation on treatment outcomes

Specialty Focus

Medical Specialties

Trauma Surgery

Documentation Requirements

Detailed documentation of the injury mechanism, physical examination findings, and any surgical interventions performed.

Common Clinical Scenarios

Management of traumatic chest injuries, including open bites and associated rib fractures.

Billing Considerations

Ensure thorough documentation of any imaging studies performed to rule out pneumothorax or hemothorax.

Emergency Medicine

Documentation Requirements

Comprehensive assessment notes, including vital signs, injury description, and treatment provided in the emergency setting.

Common Clinical Scenarios

Initial evaluation and stabilization of patients with chest trauma.

Billing Considerations

Document any immediate interventions, such as chest tube placement, if indicated.

Coding Guidelines

Inclusion Criteria

Use S21.152 When
  • Follow official ICD
  • CM guidelines for coding injuries, ensuring accurate documentation of the injury site and type
  • Include any associated injuries or complications in coding

Exclusion Criteria

Do NOT use S21.152 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 bite injury in the emergency department.

Documentation Requirements

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

Specialty Considerations

Trauma surgeons should ensure detailed operative notes are available.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of injuries, improving the granularity of data collected for trauma cases. This specificity aids in better tracking of injury patterns and outcomes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, improving the granularity of data collected for trauma cases. This specificity aids in better tracking of injury patterns and outcomes.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of injuries, improving the granularity of data collected for trauma cases. This specificity aids in better tracking of injury patterns and outcomes.

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 break the skin. Open injuries may require different management and coding.