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ICD-10 Guide
ICD-10 CodesS61.204

S61.204

Billable

Unspecified open wound of right ring finger without damage to nail

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

Code Description

ICD-10 S61.204 is a billable code used to indicate a diagnosis of unspecified open wound of right ring finger without damage to nail.

Key Diagnostic Point:

An unspecified open wound of the right ring finger without damage to the nail indicates a traumatic injury that has penetrated the skin but does not involve the nail structure. Such injuries can arise from various incidents, including cuts, lacerations, or punctures. The clinical presentation may vary from minor abrasions to more severe wounds that could potentially involve underlying structures such as tendons, nerves, or blood vessels. The absence of nail damage suggests that the injury is limited to the soft tissue of the finger. Proper assessment is crucial to determine the extent of the injury, as open wounds can lead to complications such as infection or delayed healing. Treatment typically involves cleaning the wound, possibly 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 treatment reimbursement and tracking of hand trauma cases.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in injury severity and treatment options
  • Potential for associated injuries (tendons, nerves)
  • Need for detailed documentation to specify the nature of the wound
  • Differentiation from similar codes for other finger injuries

Audit Risk Factors

  • Inadequate documentation of the injury's specifics
  • Failure to note associated injuries or complications
  • Misclassification of the wound type (open vs. closed)
  • Inconsistent coding practices across providers

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

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

Common Clinical Scenarios

Fractures associated with open wounds, tendon repairs, and nerve decompression.

Billing Considerations

Ensure that all surgical procedures are documented, including any complications that arise during treatment.

Emergency Medicine

Documentation Requirements

Thorough documentation of the mechanism of injury, initial assessment, and treatment provided in the emergency setting.

Common Clinical Scenarios

Acute trauma cases presenting with open wounds, lacerations, and potential infections.

Billing Considerations

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

Coding Guidelines

Inclusion Criteria

Use S61.204 When
  • According to ICD
  • 10 guidelines, this code should be used when the specific nature of the open wound is not documented
  • It is essential to ensure that the documentation supports the diagnosis and that the wound is indeed open without nail involvement

Exclusion Criteria

Do NOT use S61.204 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used when the open wound is sutured in the outpatient setting.

Documentation Requirements

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

Specialty Considerations

Orthopedic surgeons may perform more complex repairs if deeper structures are involved.

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 wounds. This specificity aids in better tracking of hand injuries and their treatment outcomes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including open wounds. This specificity aids in better tracking of hand injuries and their treatment outcomes.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of injuries, including open wounds. This specificity aids in better tracking of hand injuries and their 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 an open wound and a closed wound?

An open wound involves a break in the skin, exposing underlying tissues, while a closed wound does not break the skin and may involve bruising or internal damage.