Unspecified open wound of right middle finger without damage to nail
ICD-10 S61.202 is a billable code used to indicate a diagnosis of unspecified open wound of right middle finger without damage to nail.
An unspecified open wound of the right middle finger without damage to the nail indicates a traumatic injury that has penetrated the skin but does not involve the nail structure. Such wounds can result from various incidents, including cuts, lacerations, or punctures. The clinical presentation may vary, with potential symptoms including pain, swelling, and bleeding. The absence of nail damage suggests that the injury is limited to the soft tissues, which may include skin, subcutaneous tissue, and possibly deeper structures like tendons or nerves. Proper assessment is crucial to determine the extent of the injury and to rule out associated complications such as infections or tendon injuries. Treatment typically involves wound cleaning, possible suturing, and monitoring for signs of infection. In cases where deeper structures are involved, further surgical intervention may be necessary. Accurate coding is essential for appropriate management and reimbursement, as well as for tracking injury patterns in hand trauma.
Detailed notes on the mechanism of injury, examination findings, and treatment plan.
Fractures associated with open wounds, tendon repairs, and nerve decompression.
Ensure that all surgical interventions are documented, including any repairs to tendons or nerves.
Comprehensive assessment of the wound, including size, depth, and any foreign bodies.
Acute trauma cases presenting with open wounds, lacerations, and potential infections.
Document the initial treatment provided and any referrals for follow-up care.
Used when the open wound is sutured in the emergency department.
Document the size of the wound and the method of closure.
Orthopedic surgeons may perform more complex repairs if deeper structures are involved.
Document the mechanism of injury, the size and depth of the wound, any associated injuries, and the treatment provided. Ensure to note if the nail is intact.
