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ICD-10 Guide
ICD-10 CodesS71.04

S71.04

Billable

Puncture wound with foreign body of hip

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

Code Description

ICD-10 S71.04 is a billable code used to indicate a diagnosis of puncture wound with foreign body of hip.

Key Diagnostic Point:

A puncture wound with a foreign body of the hip typically occurs when an object penetrates the skin and underlying tissues, potentially damaging muscles, tendons, and other structures in the hip region. This type of injury can result from various incidents, including falls, accidents, or penetrating trauma. The presence of a foreign body complicates the injury, as it may lead to infection, delayed healing, or further tissue damage. Clinically, patients may present with localized pain, swelling, and signs of infection such as redness and discharge. Imaging studies, such as X-rays or CT scans, may be necessary to assess the extent of the injury and the location of the foreign body. Treatment often involves surgical intervention to remove the foreign object, debride any necrotic tissue, and repair any damaged structures. Post-operative care is crucial to prevent complications and ensure proper healing. This code is particularly relevant in orthopedic trauma surgery, where the management of such injuries is critical for restoring function and mobility.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Need for precise documentation of the foreign body type and location
  • Differentiation from similar codes related to hip injuries
  • Potential for associated complications requiring additional coding
  • Variability in treatment approaches based on the foreign body

Audit Risk Factors

  • Inadequate documentation of the foreign body
  • Failure to document the mechanism of injury
  • Lack of follow-up notes indicating treatment outcomes
  • Inconsistent coding of associated injuries

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed operative notes describing the procedure, foreign body removal, and any repairs made.

Common Clinical Scenarios

Patients presenting with puncture wounds from falls or accidents requiring surgical intervention.

Billing Considerations

Ensure that all surgical findings and complications are documented to support the coding.

Emergency Medicine

Documentation Requirements

Comprehensive documentation of the initial assessment, imaging results, and treatment provided.

Common Clinical Scenarios

Patients with acute puncture wounds presenting to the emergency department.

Billing Considerations

Document the mechanism of injury and any immediate interventions performed.

Coding Guidelines

Inclusion Criteria

Use S71.04 When
  • According to ICD
  • 10 guidelines, S71
  • 04 should be used when a puncture wound with a foreign body is confirmed
  • It is important to document the type of foreign body and any associated injuries

Exclusion Criteria

Do NOT use S71.04 When
  • Exclusions include cases where the foreign body is not specified or where the injury is not a puncture

Related ICD-10 Codes

Related CPT Codes

20680CPT Code

Arthrocentesis, hip joint

Clinical Scenario

Used when a foreign body is suspected in the hip joint requiring aspiration.

Documentation Requirements

Document the indication for the procedure and findings.

Specialty Considerations

Orthopedic surgeons should ensure that the procedure is justified based on clinical findings.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of injuries like puncture wounds with foreign bodies, improving the accuracy of data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries like puncture wounds with foreign bodies, improving the accuracy of data collection and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

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 primary documentation needed for coding S71.04?

The primary documentation includes a detailed description of the puncture wound, the type of foreign body, the mechanism of injury, and any surgical interventions performed.