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ICD-10 Guide
ICD-10 CodesS61.216

S61.216

Billable

Laceration without foreign body of right little finger without damage to nail

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

Code Description

ICD-10 S61.216 is a billable code used to indicate a diagnosis of laceration without foreign body of right little finger without damage to nail.

Key Diagnostic Point:

S61.216 refers to a laceration of the right little finger that does not involve a foreign body and does not damage the nail. This type of injury is common in various settings, including home accidents, sports injuries, and workplace incidents. The laceration may vary in depth and severity, potentially affecting the skin, subcutaneous tissue, and possibly underlying structures such as tendons or nerves. Proper assessment is crucial to determine the extent of the injury and to rule out complications such as infection or nerve damage. Treatment typically involves cleaning the wound, suturing if necessary, and providing appropriate follow-up care. The absence of foreign bodies simplifies the management of the injury, as there is no need for additional procedures to remove debris. However, careful documentation of the injury's characteristics, treatment provided, and any follow-up care is essential for accurate coding and billing.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Need for detailed documentation of the injury's characteristics
  • Assessment of potential underlying structures affected
  • Differentiation from similar codes for lacerations with foreign bodies
  • Consideration of associated injuries such as tendon or nerve damage

Audit Risk Factors

  • Inadequate documentation of the injury's specifics
  • Failure to note associated injuries (e.g., tendon or nerve damage)
  • Incorrect coding of related procedures
  • Lack of follow-up documentation

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Detailed description of the injury, treatment provided, and follow-up care.

Common Clinical Scenarios

Patients presenting with hand injuries from accidents, sports, or work-related incidents.

Billing Considerations

Ensure all relevant details are documented to support the diagnosis and any procedures performed.

Orthopedic Surgery

Documentation Requirements

Comprehensive assessment of the injury, including any potential tendon or nerve involvement.

Common Clinical Scenarios

Surgical intervention for severe lacerations or associated injuries requiring repair.

Billing Considerations

Document any surgical findings and post-operative care to support coding.

Coding Guidelines

Inclusion Criteria

Use S61.216 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the injury's specifics
  • Include details on the mechanism of injury, treatment provided, and any follow
  • up care

Exclusion Criteria

Do NOT use S61.216 When
  • Exclude codes for lacerations involving foreign bodies or nail damage

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used when the laceration is treated with sutures in an outpatient setting.

Documentation Requirements

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

Specialty Considerations

Emergency medicine and orthopedic surgery may both utilize this code.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of lacerations, improving the accuracy of billing and treatment tracking. S61.216 provides clarity in coding for lacerations without foreign bodies, enhancing the ability to capture the nuances of hand injuries.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of lacerations, improving the accuracy of billing and treatment tracking. S61.216 provides clarity in coding for lacerations without foreign bodies, enhancing the ability to capture the nuances of hand injuries.

Reimbursement & Billing Impact

billing and treatment tracking. S61.216 provides clarity in coding for lacerations without foreign bodies, enhancing the ability to capture the nuances of hand injuries.

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 be documented for a laceration without foreign body?

Document the mechanism of injury, depth of the laceration, treatment provided, and any follow-up care instructions.