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ICD-10 Guide
ICD-10 CodesS61.231

S61.231

Billable

Puncture wound without foreign body of left index finger without damage to nail

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

Code Description

ICD-10 S61.231 is a billable code used to indicate a diagnosis of puncture wound without foreign body of left index finger without damage to nail.

Key Diagnostic Point:

A puncture wound of the left index finger is characterized by a small, deep injury caused by a sharp object penetrating the skin without causing damage to the nail or introducing a foreign body. This type of injury can occur in various settings, including occupational accidents, household injuries, or sports-related incidents. Clinically, puncture wounds may present with localized pain, swelling, and tenderness at the site of injury. While the wound may appear minor, there is a risk of infection, particularly if the wound is not properly cleaned and treated. The absence of foreign bodies and nail damage simplifies the management of the injury, as it reduces the complexity of potential complications. Treatment typically involves thorough cleaning of the wound, possible tetanus prophylaxis, and monitoring for signs of infection. In some cases, further evaluation may be necessary to rule out deeper tissue damage, such as tendon or nerve injury, especially if the patient reports persistent pain or functional impairment. Proper documentation of the injury's mechanism, location, and treatment is essential for accurate coding and billing.

Code Complexity Analysis

Complexity Rating: Low

Low Complexity

Complexity Factors

  • Clear definition of the injury type
  • No foreign body present
  • No associated complications such as fractures or tendon injuries
  • Standard treatment protocols

Audit Risk Factors

  • Inadequate documentation of the injury mechanism
  • Failure to specify the exact location of the wound
  • Omission of treatment details
  • Misclassification of the injury type

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Detailed account of the injury mechanism, treatment provided, and follow-up care instructions.

Common Clinical Scenarios

Patients presenting with puncture wounds from various sources, including animal bites, sharp objects, or sports injuries.

Billing Considerations

Ensure that tetanus status is documented and that any signs of infection are noted.

Orthopedic Surgery

Documentation Requirements

Comprehensive assessment of potential tendon or nerve involvement, including imaging if necessary.

Common Clinical Scenarios

Patients with puncture wounds who may require surgical intervention for deeper injuries.

Billing Considerations

Document any surgical procedures performed and the rationale for intervention.

Coding Guidelines

Inclusion Criteria

Use S61.231 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the injury's specifics
  • Include details about the mechanism of injury and any treatments provided

Exclusion Criteria

Do NOT use S61.231 When
  • Exclude codes for injuries with foreign bodies or those involving nail damage

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used when the puncture wound requires suturing or closure.

Documentation Requirements

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

Specialty Considerations

Orthopedic surgeons may perform this procedure 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, improving the accuracy of medical records and billing. S61.231 provides a clear distinction from other types of injuries, facilitating better patient care and management.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, improving the accuracy of medical records and billing. S61.231 provides a clear distinction from other types of injuries, facilitating better patient care and management.

Reimbursement & Billing Impact

billing. S61.231 provides a clear distinction from other types of injuries, facilitating better patient care and 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 should I document for a puncture wound?

Document the mechanism of injury, the location of the wound, any treatment provided, and the patient's tetanus status.