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ICD-10 Guide
ICD-10 CodesS71.009

S71.009

Billable

Unspecified open wound, unspecified hip

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

Code Description

ICD-10 S71.009 is a billable code used to indicate a diagnosis of unspecified open wound, unspecified hip.

Key Diagnostic Point:

The ICD-10 code S71.009 refers to an unspecified open wound located in the hip region. Open wounds can result from various causes, including trauma, surgical procedures, or accidents. In the context of orthopedic injuries, this code is often associated with hip fractures, femoral injuries, and hip dislocations. These injuries can lead to significant morbidity, particularly in older adults, and may require surgical intervention. The management of open wounds in the hip area typically involves thorough debridement, stabilization of the fracture or dislocation, and careful monitoring for infection. Orthopedic trauma surgery may be necessary to repair the damage, which can include the use of plates, screws, or other fixation devices. Accurate coding is essential for proper reimbursement and to reflect the complexity of the patient's condition, especially when multiple injuries or complications are present.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation quality regarding the nature of the wound
  • Potential for multiple associated injuries (e.g., fractures, dislocations)
  • Need for precise anatomical localization in the hip region
  • Differentiation between open and closed wounds

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to specify the type of open wound (e.g., laceration, abrasion)
  • Lack of clarity on associated injuries or complications
  • Inconsistent coding practices among providers

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed operative notes, including the type of wound, surgical approach, and any fixation devices used.

Common Clinical Scenarios

Management of hip fractures in elderly patients, traumatic dislocations, and post-surgical complications.

Billing Considerations

Ensure that all associated injuries are documented to support the complexity of the case.

Emergency Medicine

Documentation Requirements

Comprehensive assessment notes, including mechanism of injury and initial treatment provided.

Common Clinical Scenarios

Acute trauma cases presenting with open wounds to the hip, often requiring immediate surgical consultation.

Billing Considerations

Document the patient's vital signs and any interventions performed in the emergency department.

Coding Guidelines

Inclusion Criteria

Use S71.009 When
  • Follow official coding guidelines that emphasize specificity in coding
  • Ensure that the documentation supports the use of S71
  • 009, particularly in cases with multiple injuries
  • Include any relevant external cause codes to provide context for the injury

Exclusion Criteria

Do NOT use S71.009 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

27447CPT Code

Open treatment of femoral neck fracture

Clinical Scenario

Used when performing surgical intervention for an open hip fracture.

Documentation Requirements

Operative report detailing the procedure and any complications.

Specialty Considerations

Orthopedic surgeons must ensure accurate coding to reflect the complexity of the case.

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 has improved the granularity of data for research and reimbursement purposes, but it also requires coders to be more diligent in documentation and coding practices.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including open wounds. This has improved the granularity of data for research and reimbursement purposes, but it also requires coders to be more diligent in documentation and coding practices.

Reimbursement & Billing Impact

reimbursement purposes, but it also requires coders to be more diligent in documentation and coding practices.

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. Open wounds are at higher risk for infection and may require different treatment approaches.