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ICD-10 Guide
ICD-10 CodesS81.859

S81.859

Billable

Open bite, unspecified lower leg

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

Code Description

ICD-10 S81.859 is a billable code used to indicate a diagnosis of open bite, unspecified lower leg.

Key Diagnostic Point:

An open bite in the lower leg refers to a type of injury characterized by a break in the skin and underlying tissues, typically resulting from trauma. This injury can occur due to various mechanisms, including falls, sports injuries, or accidents. The open bite may involve damage to the skin, subcutaneous tissues, and potentially the underlying structures such as muscles, tendons, and bones. In the context of knee injuries, an open bite can complicate the assessment of associated injuries, such as tibial or fibular fractures, ligament tears, or other orthopedic conditions. The presence of an open bite may increase the risk of infection and necessitate careful management, including possible surgical intervention to clean the wound and repair any damaged structures. Orthopedic reconstructive procedures may be required to restore function and stability to the lower leg, particularly if there is associated damage to ligaments or fractures. 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 the injury mechanism
  • Potential for associated injuries complicating coding
  • Need for precise anatomical localization
  • Differentiation from similar codes for closed injuries

Audit Risk Factors

  • Inadequate documentation of the injury mechanism
  • Failure to note associated injuries or complications
  • Misclassification of the injury type (open vs. closed)
  • Lack of follow-up documentation on treatment outcomes

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

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

Common Clinical Scenarios

Fractures associated with open bites, ligament repairs, and reconstructive surgeries.

Billing Considerations

Ensure clear documentation of the injury's open nature and any associated complications.

Emergency Medicine

Documentation Requirements

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

Common Clinical Scenarios

Patients presenting with trauma to the lower leg, requiring immediate care for open wounds.

Billing Considerations

Document all findings and treatments to support coding for potential surgical interventions.

Coding Guidelines

Inclusion Criteria

Use S81.859 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the injury type and any associated conditions
  • Include details on the mechanism of injury and any surgical interventions performed

Exclusion Criteria

Do NOT use S81.859 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

11042CPT Code

Debridement, skin, subcutaneous tissue

Clinical Scenario

Used for wound care of an open bite.

Documentation Requirements

Document the extent of debridement and any associated procedures.

Specialty Considerations

Orthopedic surgeons may perform this in conjunction with fracture repair.

27506CPT Code

Open treatment of tibial fracture

Clinical Scenario

Used when an open bite is associated with a tibial fracture.

Documentation Requirements

Detail the fracture type and treatment performed.

Specialty Considerations

Orthopedic documentation must include surgical notes.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of open bites, improving the ability to capture the complexity of these injuries and their treatment needs.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of open bites, improving the ability to capture the complexity of these injuries and their treatment needs.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of open bites, improving the ability to capture the complexity of these injuries and their treatment needs.

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 underlying tissues, while a closed fracture does not involve any skin breach.