Unspecified open wound of right middle finger with damage to nail
ICD-10 S61.302 is a billable code used to indicate a diagnosis of unspecified open wound of right middle finger with damage to nail.
An unspecified open wound of the right middle finger with damage to the nail indicates a traumatic injury that has penetrated the skin and may involve the underlying structures of the finger. This type of injury can occur due to various incidents such as cuts, lacerations, or punctures. The damage to the nail may include partial or complete avulsion, which can lead to complications such as infection, nail deformity, or permanent nail loss. The clinical management of such injuries often requires thorough assessment to rule out associated injuries, including fractures of the phalanges, tendon injuries, or nerve damage. Treatment may involve wound cleaning, suturing, and possibly surgical intervention if deeper structures are involved. Proper documentation is crucial to capture the extent of the injury and any associated procedures performed, as this will impact coding and reimbursement.
Detailed notes on the mechanism of injury, physical examination findings, and treatment plan.
Fractures associated with open wounds, tendon repairs, and nail bed injuries.
Ensure to document any surgical interventions performed, including the type of repair and any implants used.
Comprehensive assessment of the wound, including size, depth, and any foreign bodies.
Acute trauma cases presenting with open wounds and potential for infection.
Document the initial treatment provided, including wound care and any referrals made.
Used when the wound requires suturing or closure.
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 extent of the wound, any associated injuries, and the treatment provided.
