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ICD-10 Guide
ICD-10 CodesS41.011

S41.011

Billable

Laceration without foreign body of right shoulder

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/24/2025

Code Description

ICD-10 S41.011 is a billable code used to indicate a diagnosis of laceration without foreign body of right shoulder.

Key Diagnostic Point:

S41.011 refers to a laceration of the right shoulder that does not involve any foreign body. This type of injury typically results from trauma, such as falls, sports injuries, or accidents. The shoulder is a complex joint that allows for a wide range of motion, making it susceptible to various injuries. A laceration in this area can affect the skin, subcutaneous tissue, and potentially deeper structures, including muscles and tendons. It is crucial to assess the extent of the laceration, as deeper injuries may involve the rotator cuff or other shoulder structures, leading to complications such as instability or impaired function. Treatment often involves cleaning the wound, suturing if necessary, and monitoring for signs of infection. In cases where the laceration is associated with other shoulder injuries, such as dislocations or fractures, comprehensive management is required to ensure optimal recovery and restore shoulder function.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between types of shoulder injuries (e.g., laceration vs. fracture)
  • Assessing the depth and extent of the laceration
  • Potential association with other shoulder conditions (e.g., dislocations, rotator cuff injuries)
  • Documentation of the mechanism of injury

Audit Risk Factors

  • Inadequate documentation of the injury mechanism
  • Failure to specify the depth of the laceration
  • Misclassification of the injury type (e.g., laceration vs. contusion)
  • Lack of follow-up documentation regarding treatment outcomes

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed description of the injury, treatment plan, and any surgical interventions performed.

Common Clinical Scenarios

Lacerations resulting from sports injuries, falls, or accidents requiring surgical repair.

Billing Considerations

Ensure accurate coding of any associated injuries, such as fractures or dislocations, and document the surgical approach if applicable.

Emergency Medicine

Documentation Requirements

Comprehensive assessment of the injury, including mechanism of injury and initial treatment provided.

Common Clinical Scenarios

Patients presenting with acute shoulder injuries following trauma.

Billing Considerations

Document the patient's vital signs and any immediate interventions performed to support coding.

Coding Guidelines

Inclusion Criteria

Use S41.011 When
  • According to ICD
  • 10 guidelines, S41
  • 011 should be used when documenting a laceration of the right shoulder without foreign body involvement
  • Coders must ensure that the documentation supports the diagnosis and reflects the specifics of the injury

Exclusion Criteria

Do NOT use S41.011 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used for suturing a laceration on the right shoulder.

Documentation Requirements

Document the size and depth of the laceration.

Specialty Considerations

Orthopedic surgeons may need to document any associated injuries.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of shoulder injuries, including lacerations. This specificity aids in better tracking of injury types and treatment outcomes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of shoulder injuries, including lacerations. This specificity aids in better tracking of injury types and treatment outcomes.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of shoulder injuries, including lacerations. This specificity aids in better tracking of injury types and treatment 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 S41.011 and S41.012?

S41.011 is used for lacerations of the right shoulder without foreign body, while S41.012 is for lacerations of the left shoulder without foreign body.