Unspecified open wound of right hand
ICD-10 S61.401 is a billable code used to indicate a diagnosis of unspecified open wound of right hand.
An unspecified open wound of the right hand refers to a traumatic injury that results in a break in the skin and exposure of underlying tissues, without a specific classification of the wound type (e.g., laceration, abrasion, or puncture). Such injuries can occur due to various mechanisms, including cuts from sharp objects, crush injuries, or bites. The right hand is particularly susceptible to injuries due to its frequent use in daily activities and occupational tasks. Open wounds can lead to complications such as infection, delayed healing, and potential damage to underlying structures, including tendons, nerves, and blood vessels. The clinical management of these wounds often involves thorough cleaning, possible suturing, and monitoring for signs of infection. In cases where deeper structures are involved, surgical intervention may be necessary to repair damaged tendons or nerves. Accurate coding is essential for proper treatment documentation and reimbursement, as well as for tracking injury patterns and outcomes in hand trauma cases.
Detailed descriptions of the injury, treatment plan, and any surgical procedures performed.
Fractures associated with open wounds, tendon repairs, and nerve decompression.
Ensure that all surgical interventions are documented, including pre-operative and post-operative assessments.
Comprehensive notes on the mechanism of injury, initial assessment, and treatment provided in the emergency setting.
Acute trauma cases presenting with open wounds, potential infections, and immediate surgical needs.
Document all interventions performed in the emergency department, including imaging and consultations.
Used for suturing an open wound on the right hand.
Document the size of the wound and the method of repair.
Orthopedic surgeons may also document any associated tendon repairs.
Used when a tendon injury is identified during the treatment of an open wound.
Detailed notes on the tendon involved and the repair technique used.
Ensure that the repair is documented in conjunction with the open wound diagnosis.
Use S61.401 when the documentation does not specify the type of open wound or when the injury details are insufficient to assign a more specific code.
