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ICD-10 Guide
ICD-10 CodesS71.139

S71.139

Billable

Puncture wound without foreign body, unspecified thigh

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/25/2025

Code Description

ICD-10 S71.139 is a billable code used to indicate a diagnosis of puncture wound without foreign body, unspecified thigh.

Key Diagnostic Point:

A puncture wound without foreign body in the thigh is a type of injury characterized by a small, deep wound caused by a sharp object that penetrates the skin and underlying tissues. This injury can occur in various settings, including accidents, sports injuries, or assaults. The thigh, being a large muscle group, can sustain significant trauma, leading to complications such as infection, hematoma, or damage to underlying structures like muscles, nerves, and blood vessels. In cases where the puncture is deep, there may be a risk of injury to the femur or surrounding soft tissues. Proper assessment and management are crucial to prevent complications. Treatment typically involves cleaning the wound, assessing for any foreign bodies, and monitoring for signs of infection. In some cases, surgical intervention may be necessary to repair damaged tissues or to drain any accumulated fluid. Accurate coding of this injury is essential for appropriate treatment planning and reimbursement.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation of the injury site and depth
  • Potential for associated injuries (e.g., muscle, nerve damage)
  • Differentiation from similar codes (e.g., open wounds, lacerations)
  • Need for precise clinical details to support coding

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to specify the depth of the puncture wound
  • Lack of follow-up documentation indicating treatment outcomes
  • Misclassification of the wound type (e.g., laceration vs. puncture)

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed descriptions of the injury, treatment provided, and any surgical interventions performed.

Common Clinical Scenarios

Management of puncture wounds resulting from sports injuries or falls, often requiring surgical intervention.

Billing Considerations

Documentation should include any associated injuries to the femur or surrounding structures, as well as the need for imaging studies.

Emergency Medicine

Documentation Requirements

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

Common Clinical Scenarios

Patients presenting with puncture wounds from accidents or assaults, requiring immediate care.

Billing Considerations

Ensure that all relevant details about the injury and treatment are documented to support coding.

Coding Guidelines

Inclusion Criteria

Use S71.139 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the code is used for puncture wounds without foreign bodies
  • Include any relevant details about the injury's location and severity

Exclusion Criteria

Do NOT use S71.139 When
  • Exclude codes for open wounds or lacerations unless specified

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used when a puncture wound requires simple closure.

Documentation Requirements

Document the size of the wound and the method of closure.

Specialty Considerations

Orthopedic surgeons may need to provide additional details about the injury.

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 puncture wounds, which enhances the accuracy of patient records and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including puncture wounds, which enhances the accuracy of patient records 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 difference between a puncture wound and a laceration?

A puncture wound is a deep, narrow injury caused by a sharp object, while a laceration is a tear or cut in the skin that may be wider and more superficial.