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ICD-10 Guide
ICD-10 CodesS61.101

S61.101

Billable

Unspecified open wound of right thumb with damage to nail

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

Code Description

ICD-10 S61.101 is a billable code used to indicate a diagnosis of unspecified open wound of right thumb with damage to nail.

Key Diagnostic Point:

An unspecified open wound of the right thumb with damage to the nail indicates a traumatic injury that has penetrated the skin and may involve the underlying structures of the thumb. This type of injury can occur due to various mechanisms such as lacerations, punctures, or avulsions. The damage to the nail may include partial or complete loss of the nail plate, which can lead to complications such as infection, nail deformity, or delayed healing. The clinical management of this condition often involves thorough cleaning of the wound, possible suturing, and monitoring for signs of infection. In cases where the nail matrix is affected, surgical intervention may be necessary to repair the nail bed or matrix to ensure proper nail regrowth. The complexity of treatment can vary based on the extent of the injury and the presence of associated injuries such as fractures or tendon damage. Accurate coding is essential for appropriate reimbursement and to reflect the severity of the injury in the patient's medical record.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in the extent of the wound and associated injuries
  • Need for detailed documentation of the injury mechanism
  • Potential for co-existing conditions (e.g., fractures, tendon injuries)
  • Variability in treatment approaches and surgical interventions

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to specify the extent of nail damage
  • Lack of follow-up documentation regarding healing
  • Inconsistent coding of associated injuries

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed operative notes, including descriptions of any repairs to the nail bed or associated structures.

Common Clinical Scenarios

Management of open wounds with associated fractures or tendon injuries.

Billing Considerations

Ensure that all associated injuries are documented and coded appropriately.

Plastic Surgery

Documentation Requirements

Comprehensive documentation of wound assessment and surgical interventions performed.

Common Clinical Scenarios

Reconstruction of the nail bed or repair of complex hand injuries.

Billing Considerations

Document the aesthetic and functional outcomes of surgical procedures.

Coding Guidelines

Inclusion Criteria

Use S61.101 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the code accurately reflects the specific injury and any associated conditions
  • Include details about the mechanism of injury and any surgical procedures performed

Exclusion Criteria

Do NOT use S61.101 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 wound on the right thumb.

Documentation Requirements

Document the size and depth of the wound, and any associated procedures.

Specialty Considerations

Orthopedic or plastic surgery specialties may have specific requirements for documentation.

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 the distinction between open and closed wounds, which enhances the accuracy of medical records and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including the distinction between open and closed wounds, which enhances the accuracy of medical records 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 should I document for an open wound of the thumb?

Document the mechanism of injury, the extent of the wound, any damage to the nail, and any associated injuries or treatments provided.