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ICD-10 Guide
ICD-10 CodesS81.84

S81.84

Billable

Puncture wound with foreign body of lower leg

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

Code Description

ICD-10 S81.84 is a billable code used to indicate a diagnosis of puncture wound with foreign body of lower leg.

Key Diagnostic Point:

A puncture wound with a foreign body of the lower leg typically occurs when a sharp object penetrates the skin and underlying tissues, potentially introducing foreign materials such as dirt, metal, or glass into the wound. This type of injury can lead to complications such as infection, delayed healing, and damage to surrounding structures, including muscles, nerves, and blood vessels. In the context of knee injuries, puncture wounds may occur during sports activities or accidents, where the knee is exposed to sharp objects. The presence of a foreign body complicates the healing process and may necessitate surgical intervention to remove the object and clean the wound. Additionally, if the puncture wound is associated with fractures of the tibia or fibula, or ligament tears, it may require comprehensive orthopedic evaluation and treatment. Orthopedic reconstructive procedures may be indicated if there is significant damage to the knee joint or surrounding soft tissues. Proper assessment and management are crucial to prevent long-term complications and ensure optimal recovery.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Presence of foreign body complicates coding and treatment.
  • Potential for associated injuries (fractures, ligament tears).
  • Variability in documentation quality across providers.
  • Need for precise anatomical localization in coding.

Audit Risk Factors

  • Inadequate documentation of the foreign body type and location.
  • Failure to document associated injuries (e.g., fractures).
  • Misclassification of the wound type (puncture vs. laceration).
  • Lack of clarity on treatment provided (e.g., removal of foreign body).

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed operative notes describing the procedure, foreign body removal, and any associated repairs.

Common Clinical Scenarios

Management of puncture wounds with foreign bodies leading to knee injuries or fractures.

Billing Considerations

Ensure clear documentation of the foreign body type and any associated orthopedic injuries.

Emergency Medicine

Documentation Requirements

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

Common Clinical Scenarios

Initial evaluation and management of puncture wounds in the emergency department.

Billing Considerations

Document the need for imaging studies if fractures are suspected.

Coding Guidelines

Inclusion Criteria

Use S81.84 When
  • Follow official ICD
  • CM coding guidelines, ensuring accurate documentation of the wound type, foreign body presence, and any associated injuries
  • Include details on the treatment provided and any complications

Exclusion Criteria

Do NOT use S81.84 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

11042CPT Code

Debridement, skin, and subcutaneous tissue

Clinical Scenario

Used when debridement is necessary for a puncture wound with foreign body.

Documentation Requirements

Document the extent of debridement and any foreign body removal.

Specialty Considerations

Orthopedic surgeons should ensure detailed operative notes.

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 with foreign bodies. This specificity helps in better tracking of injury types and associated complications, 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 with foreign bodies. This specificity helps in better tracking of injury types and associated complications, 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 with foreign bodies. This specificity helps in better tracking of injury types and associated complications, 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 S81.84 and S81.83?

S81.84 is used for puncture wounds with a foreign body present, while S81.83 is for puncture wounds without a foreign body. Accurate documentation is essential to determine which code to use.