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ICD-10 Guide
ICD-10 CodesS81.83

S81.83

Billable

Puncture wound without foreign body of lower leg

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/26/2025

Code Description

ICD-10 S81.83 is a billable code used to indicate a diagnosis of puncture wound without foreign body of lower leg.

Key Diagnostic Point:

A puncture wound without foreign body of the lower leg refers to an injury characterized by a small, deep wound caused by a sharp object penetrating the skin and underlying tissues, typically affecting the knee, tibia, or fibula. This type of injury can occur in various scenarios, such as accidents involving sharp tools, falls, or sports injuries. Unlike lacerations, puncture wounds are often less visible but can lead to significant complications, including infection, damage to underlying structures like ligaments, tendons, or nerves, and delayed healing. In the context of knee injuries, a puncture wound may coincide with ligament tears or fractures of the tibia or fibula, necessitating careful assessment and management. Treatment may involve cleaning the wound, monitoring for infection, and in some cases, surgical intervention to repair any associated damage. Accurate coding is essential for proper reimbursement and to reflect the complexity of care provided.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between puncture wounds and other types of wounds.
  • Identifying associated injuries such as fractures or ligament tears.
  • Documenting the absence of foreign bodies accurately.
  • Understanding the implications of the injury on potential surgical interventions.

Audit Risk Factors

  • Inadequate documentation of the injury mechanism.
  • Failure to note associated injuries like fractures or ligament tears.
  • Misclassification of the wound type.
  • Lack of follow-up documentation regarding treatment and healing.

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Detailed descriptions of the injury, associated fractures, and treatment plans.

Common Clinical Scenarios

Puncture wounds resulting from sports injuries or falls leading to knee instability.

Billing Considerations

Ensure documentation reflects any surgical interventions or orthopedic assessments.

Emergency Medicine

Documentation Requirements

Thorough initial assessment notes, including mechanism of injury and any immediate interventions.

Common Clinical Scenarios

Patients presenting with puncture wounds from accidents or altercations.

Billing Considerations

Documenting the patient's vital signs and any signs of infection or complications.

Coding Guidelines

Inclusion Criteria

Use S81.83 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the injury type, location, and any associated conditions
  • Include details about the absence of foreign bodies and any treatment provided

Exclusion Criteria

Do NOT use S81.83 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used for the repair of a puncture wound without complications.

Documentation Requirements

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

Specialty Considerations

Orthopedic specialists may need to document any additional procedures performed.

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 helps in better tracking of injury types and outcomes, leading to improved patient care and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including puncture wounds, which helps in better tracking of injury types and outcomes, leading to improved patient care and resource allocation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of injuries, including puncture wounds, which helps in better tracking of injury types and outcomes, leading to improved patient care 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 a puncture wound and a laceration?

A puncture wound is a small, deep wound caused by a sharp object, while a laceration is a tear or cut in the skin that may be wider and more superficial. Puncture wounds can be more dangerous due to the risk of infection and damage to deeper structures.