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ICD-10 Guide
ICD-10 CodesS81.852

S81.852

Billable

Open bite, left lower leg

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

Code Description

ICD-10 S81.852 is a billable code used to indicate a diagnosis of open bite, left lower leg.

Key Diagnostic Point:

An open bite in the left lower leg refers to a wound or injury characterized by a break in the skin and underlying tissues, exposing the underlying structures. This type of injury can occur due to various mechanisms, including trauma from falls, accidents, or penetrating injuries. Open bites can lead to complications such as infection, delayed healing, and potential damage to the underlying bones, ligaments, and tendons. In the context of knee injuries, an open bite may be associated with fractures of the tibia or fibula, ligament tears, or other orthopedic conditions. Proper assessment and management are crucial to prevent complications and ensure optimal recovery. Treatment may involve surgical intervention, especially if there is significant soft tissue damage or if the fracture is displaced. Rehabilitation may also be necessary to restore function and strength to the affected leg. Accurate coding of this condition is essential for appropriate treatment planning and reimbursement.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation of injury severity and type
  • Potential for associated fractures or ligament injuries
  • Need for detailed descriptions of the injury mechanism
  • Variability in treatment approaches and surgical interventions

Audit Risk Factors

  • Inadequate documentation of the injury mechanism
  • Failure to document associated injuries or complications
  • Misclassification of the type of bite (open vs. closed)
  • Lack of clarity in treatment plans and follow-up care

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed descriptions of the injury, treatment plans, and any surgical procedures performed.

Common Clinical Scenarios

Management of open fractures, ligament repairs, and reconstructive procedures following trauma.

Billing Considerations

Documentation must clearly indicate the extent of soft tissue damage and any associated fractures.

Emergency Medicine

Documentation Requirements

Accurate recording of initial assessment, mechanism of injury, and immediate treatment provided.

Common Clinical Scenarios

Initial evaluation and stabilization of patients with open leg injuries.

Billing Considerations

Timely documentation is critical for coding and billing, especially in trauma cases.

Coding Guidelines

Inclusion Criteria

Use S81.852 When
  • According to ICD
  • 10 coding guidelines, S81
  • 852 should be used when there is a clear indication of an open bite in the left lower leg
  • Coders must ensure that documentation supports the diagnosis and any associated injuries

Exclusion Criteria

Do NOT use S81.852 When
  • Exclusions include conditions that do not involve an open wound

Related ICD-10 Codes

Related CPT Codes

27814CPT Code

Open treatment of tibial fracture

Clinical Scenario

Used when surgical intervention is required for an open fracture.

Documentation Requirements

Surgical notes must detail the procedure and any complications.

Specialty Considerations

Orthopedic surgeons must ensure accurate coding for surgical interventions.

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 open bites, 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 open bites, 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 an open bite and a closed fracture?

An open bite involves a break in the skin and exposure of underlying tissues, while a closed fracture does not break the skin and is contained within the body.