Puncture wound without foreign body, unspecified lower leg
ICD-10 S81.839 is a billable code used to indicate a diagnosis of puncture wound without foreign body, unspecified lower leg.
A puncture wound without foreign body in the lower leg refers to an injury characterized by a small, deep wound caused by a sharp object that penetrates the skin and underlying tissues. This type of injury can occur in various scenarios, such as accidents involving sharp tools, animal bites, or falls. The lower leg encompasses the area between the knee and the ankle, including the tibia and fibula. While puncture wounds are generally less severe than lacerations or abrasions, they can lead to complications such as infection, especially if not properly cleaned and treated. In cases where the wound is deep, there may be damage to underlying structures, including muscles, tendons, and ligaments. It is crucial for healthcare providers to assess the wound thoroughly, considering the potential for associated injuries, such as ligament tears or fractures, particularly in active individuals. Treatment may involve cleaning the wound, monitoring for signs of infection, and in some cases, surgical intervention may be necessary to repair any damaged structures or to ensure proper healing.
Detailed descriptions of the injury, treatment provided, and any associated injuries.
Fractures associated with puncture wounds, ligament tears due to trauma.
Ensure that all associated injuries are documented to support the coding of multiple conditions.
Immediate assessment notes, treatment provided, and follow-up care instructions.
Patients presenting with puncture wounds from accidents or animal bites.
Timely documentation is critical for accurate coding and billing.
Used for the repair of a puncture wound without complications.
Document the size of the wound and the method of repair.
Orthopedic specialists may need to document any associated injuries.
S81.839 is used for puncture wounds without foreign bodies, while S81.839A is for puncture wounds that involve a foreign body.
