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ICD-10 Guide
ICD-10 CodesS71.1

S71.1

Billable

Open wound of thigh

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

Code Description

ICD-10 S71.1 is a billable code used to indicate a diagnosis of open wound of thigh.

Key Diagnostic Point:

An open wound of the thigh refers to a traumatic injury that results in a break in the skin and underlying tissues in the thigh region. This type of injury can occur due to various mechanisms, including falls, motor vehicle accidents, or penetrating injuries. Open wounds can range from superficial abrasions to deep lacerations that may involve muscles, tendons, and even bones. In the context of orthopedic trauma, open wounds of the thigh are particularly concerning due to the risk of infection, significant blood loss, and potential complications such as delayed healing or non-union of fractures. Treatment often involves surgical intervention to clean the wound, repair damaged tissues, and stabilize any associated fractures, such as femoral neck or shaft fractures. The management of these injuries requires a multidisciplinary approach, including orthopedic surgeons, trauma specialists, and rehabilitation teams to ensure optimal recovery and functional outcomes.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of potential associated injuries (e.g., fractures, dislocations)
  • Need for detailed documentation of wound characteristics
  • Variability in treatment approaches based on injury severity
  • Potential for multiple codes to be applicable (e.g., for fractures or dislocations)

Audit Risk Factors

  • Inadequate documentation of the wound's size and depth
  • Failure to document associated injuries (e.g., fractures)
  • Lack of clarity on the mechanism of injury
  • Inconsistent coding of follow-up visits or complications

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed operative reports, including descriptions of the wound, any fractures, and surgical interventions performed.

Common Clinical Scenarios

Open fractures of the femur, traumatic lacerations requiring surgical repair, and management of associated hip dislocations.

Billing Considerations

Ensure that all associated injuries are documented and coded appropriately to reflect the complexity of the case.

Emergency Medicine

Documentation Requirements

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

Common Clinical Scenarios

Patients presenting with traumatic injuries from falls or accidents, requiring immediate evaluation and stabilization.

Billing Considerations

Accurate documentation of the patient's condition upon arrival and any interventions performed is crucial for proper coding.

Coding Guidelines

Inclusion Criteria

Use S71.1 When
  • According to ICD
  • 10 coding guidelines, S71
  • 1 should be used when there is a documented open wound of the thigh
  • Coders must ensure that the documentation supports the diagnosis and any associated injuries

Exclusion Criteria

Do NOT use S71.1 When
  • Exclusions include closed wounds or wounds located in other anatomical regions

Related ICD-10 Codes

Related CPT Codes

12002CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used for initial treatment of open wounds in the outpatient setting.

Documentation Requirements

Document the size and depth of the wound, as well as the method of repair.

Specialty Considerations

Orthopedic surgeons may also perform more complex repairs requiring additional coding.

27506CPT Code

Open treatment of femoral fracture

Clinical Scenario

Used when surgical intervention is required for an open fracture of the thigh.

Documentation Requirements

Detailed operative report outlining the procedure performed and any complications.

Specialty Considerations

Ensure that all associated injuries are documented.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of open wounds, improving the ability to capture the complexity of injuries and associated treatments. This specificity aids in better patient management and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of open wounds, improving the ability to capture the complexity of injuries and associated treatments. This specificity aids in better patient management and resource allocation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of open wounds, improving the ability to capture the complexity of injuries and associated treatments. This specificity aids in better patient management and resource allocation.

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 and may involve bruising or internal damage.