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ICD-10 Guide
ICD-10 CodesS71.10

S71.10

Billable

Unspecified open wound of thigh

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

Code Description

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

Key Diagnostic Point:

An unspecified 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, without specific details regarding the nature or extent of the wound. This type of injury can occur due to various mechanisms, including falls, motor vehicle accidents, or penetrating injuries. Open wounds can lead to significant complications such as infection, hemorrhage, and delayed healing. In the context of orthopedic trauma, these wounds may be associated with underlying fractures, particularly of the femur or hip, necessitating careful evaluation and management. Treatment often involves surgical intervention, including debridement, stabilization of fractures, and repair of soft tissue. The complexity of managing open wounds in the thigh is heightened by the potential for associated injuries, such as hip fractures or dislocations, which may require orthopedic surgery. Accurate coding is essential for appropriate reimbursement and to reflect the severity of the injury in clinical documentation.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in wound classification (e.g., depth, contamination)
  • Potential for associated fractures or dislocations
  • Need for surgical intervention and follow-up care
  • Documentation of wound care and management

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to specify the type of open wound
  • Lack of detail regarding associated injuries
  • Inconsistent coding of related procedures

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed descriptions of the wound, associated injuries, and surgical procedures performed.

Common Clinical Scenarios

Management of open fractures, surgical debridement, and fixation of femoral fractures.

Billing Considerations

Ensure clear documentation of the surgical approach and any complications encountered during the procedure.

Emergency Medicine

Documentation Requirements

Thorough documentation of the initial assessment, mechanism of injury, and treatment provided in the emergency setting.

Common Clinical Scenarios

Initial evaluation and stabilization of patients with traumatic open wounds and potential fractures.

Billing Considerations

Accurate coding of the injury type and associated procedures performed in the emergency department.

Coding Guidelines

Inclusion Criteria

Use S71.10 When
  • According to ICD
  • 10 coding guidelines, S71
  • 10 should be used when the specific type of open wound is not documented
  • Coders should ensure that the documentation supports the use of this code and consider any associated injuries that may require additional coding

Exclusion Criteria

Do NOT use S71.10 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used for initial treatment of open wounds in the thigh.

Documentation Requirements

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

Specialty Considerations

Orthopedic surgeons may need to document additional details if associated fractures are present.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of injuries, which can improve the accuracy of claims and better reflect the severity of injuries. S71.10 provides a general classification for unspecified open wounds, but coders should strive for specificity when possible.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, which can improve the accuracy of claims and better reflect the severity of injuries. S71.10 provides a general classification for unspecified open wounds, but coders should strive for specificity when possible.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of injuries, which can improve the accuracy of claims and better reflect the severity of injuries. S71.10 provides a general classification for unspecified open wounds, but coders should strive for specificity when possible.

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

When should I use S71.10?

Use S71.10 when there is an unspecified open wound of the thigh, and no further details about the wound type or associated injuries are documented.