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v1.0.0
ICD-10 Guide
ICD-10 CodesS41.159

S41.159

Billable

Open bite of unspecified upper arm

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

Code Description

ICD-10 S41.159 is a billable code used to indicate a diagnosis of open bite of unspecified upper arm.

Key Diagnostic Point:

An open bite of the upper arm refers to a wound that penetrates the skin and underlying tissues, resulting from a bite injury. This type of injury can occur in various contexts, including animal bites or human bites, and may lead to significant soft tissue damage, potential infection, and complications such as necrosis or delayed healing. The upper arm encompasses the area between the shoulder and the elbow, and injuries in this region can affect not only the skin but also the underlying muscles, nerves, and blood vessels. Clinical evaluation typically involves assessing the depth and extent of the wound, the presence of foreign bodies, and the need for surgical intervention. Treatment may include wound cleaning, debridement, and possibly surgical repair, especially if there is significant tissue loss or if the bite has penetrated deeply. The management of open bite injuries often requires a multidisciplinary approach, including orthopedic evaluation if there is concern for associated fractures or joint involvement.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of potential causes (animal vs. human bites)
  • Need for detailed documentation of wound characteristics
  • Potential for associated injuries (e.g., fractures, nerve damage)
  • Variability in treatment protocols based on severity

Audit Risk Factors

  • Inadequate documentation of the injury mechanism
  • Failure to note associated injuries or complications
  • Misclassification of the injury type (open vs. closed)
  • Lack of follow-up documentation on healing or treatment outcomes

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed descriptions of the injury, treatment provided, and any surgical interventions performed.

Common Clinical Scenarios

Management of open bite injuries requiring surgical repair, assessment of associated fractures.

Billing Considerations

Ensure accurate coding of any concurrent procedures performed during surgical intervention.

Emergency Medicine

Documentation Requirements

Thorough documentation of the initial assessment, wound characteristics, and any immediate interventions.

Common Clinical Scenarios

Initial evaluation and treatment of bite wounds, including potential for infection.

Billing Considerations

Document the mechanism of injury clearly to support the diagnosis and treatment provided.

Coding Guidelines

Inclusion Criteria

Use S41.159 When
  • According to ICD
  • 10 guidelines, S41
  • 159 should be used when the specific site of the open bite is not documented
  • Coders should ensure that the documentation supports the diagnosis and that any associated injuries are also coded appropriately

Exclusion Criteria

Do NOT use S41.159 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used when performing a simple repair of an open bite wound.

Documentation Requirements

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

Specialty Considerations

Orthopedic surgeons may need to document any additional procedures performed.

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 open bites, which can improve data accuracy and facilitate better patient care management.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including open bites, which can improve data accuracy and facilitate better patient care management.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of injuries, including open bites, which can improve data accuracy and facilitate better patient care 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 is the difference between an open bite and a closed bite?

An open bite involves a break in the skin and exposure of underlying tissues, while a closed bite does not penetrate the skin.