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v1.0.0
ICD-10 Guide
ICD-10 CodesS41.019

S41.019

Billable

Laceration without foreign body of unspecified shoulder

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

Code Description

ICD-10 S41.019 is a billable code used to indicate a diagnosis of laceration without foreign body of unspecified shoulder.

Key Diagnostic Point:

S41.019 refers to a laceration of the shoulder region that does not involve any foreign body. This injury can occur due to various mechanisms, including trauma from falls, sports injuries, or accidents. The shoulder is a complex joint that includes the humerus, scapula, and clavicle, and is surrounded by muscles, tendons, and ligaments. A laceration in this area can lead to complications such as infection, impaired mobility, and potential damage to underlying structures. It is crucial for healthcare providers to assess the extent of the laceration, including any associated injuries like dislocations, fractures, or rotator cuff injuries. Proper documentation of the injury's location, depth, and any associated symptoms is essential for accurate coding and treatment planning. Treatment may involve wound care, suturing, and in some cases, surgical intervention if deeper structures are involved. Understanding the implications of this code is vital for ensuring appropriate management and reimbursement.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation quality regarding the extent of the laceration.
  • Potential for associated injuries that may complicate coding.
  • Need for precise anatomical terminology to avoid misclassification.
  • Differentiation from similar codes related to shoulder injuries.

Audit Risk Factors

  • Inadequate documentation of the injury's specifics.
  • Failure to document associated injuries or complications.
  • Misuse of codes for similar shoulder injuries.
  • Inconsistent coding practices across different providers.

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed descriptions of the laceration, associated injuries, and treatment plans.

Common Clinical Scenarios

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

Billing Considerations

Ensure all associated injuries are documented to support coding and billing.

Emergency Medicine

Documentation Requirements

Immediate assessment notes, including mechanism of injury and initial treatment provided.

Common Clinical Scenarios

Patients presenting with acute shoulder lacerations after trauma.

Billing Considerations

Timely documentation is crucial for accurate coding and treatment follow-up.

Coding Guidelines

Inclusion Criteria

Use S41.019 When
  • Follow official ICD
  • CM guidelines for coding injuries, ensuring accurate documentation of the injury's specifics and any associated conditions
  • Include details about the mechanism of injury and treatment provided

Exclusion Criteria

Do NOT use S41.019 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 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, improving the accuracy of diagnoses and treatment plans. S41.019 provides a clear distinction for lacerations without foreign bodies, aiding in better patient management.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of shoulder injuries, improving the accuracy of diagnoses and treatment plans. S41.019 provides a clear distinction for lacerations without foreign bodies, aiding in better patient management.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of shoulder injuries, improving the accuracy of diagnoses and treatment plans. S41.019 provides a clear distinction for lacerations without foreign bodies, aiding in better patient management.

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 should I document for a laceration without foreign body?

Document the location, depth, mechanism of injury, and any associated injuries or treatments provided.