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ICD-10 Guide
ICD-10 CodesS01.81

S01.81

Billable

Laceration without foreign body of other part of head

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 S01.81 is a billable code used to indicate a diagnosis of laceration without foreign body of other part of head.

Key Diagnostic Point:

S01.81 refers to a laceration of the head that does not involve a foreign body. This type of injury can occur due to various mechanisms, including blunt trauma, falls, or accidents involving sharp objects. Clinically, lacerations can vary in depth and severity, affecting not only the skin but potentially underlying tissues such as muscles, nerves, and blood vessels. The absence of a foreign body distinguishes this code from other laceration codes that may involve embedded objects. Proper assessment involves a thorough physical examination, often supplemented by imaging studies if deeper structures are suspected to be involved. Management typically includes wound cleaning, possible suturing, and monitoring for complications such as infection or excessive bleeding. Understanding the mechanism of injury is crucial for appropriate treatment and coding.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between types of lacerations (e.g., with vs. without foreign body)
  • Assessing the depth and severity of the laceration
  • Documenting the mechanism of injury accurately
  • Understanding the anatomical location of the laceration

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to specify the depth of the laceration
  • Misclassification of laceration type
  • Omission of associated injuries

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Documentation must include a detailed description of the injury, mechanism of injury, and any immediate interventions performed.

Common Clinical Scenarios

Patients presenting with lacerations from falls, sports injuries, or accidents.

Billing Considerations

Ensure that the mechanism of injury is clearly documented to support the diagnosis and coding.

Surgery

Documentation Requirements

Operative reports should detail the procedure performed, including any repairs or interventions on the laceration.

Common Clinical Scenarios

Surgical repair of lacerations requiring suturing or other closure methods.

Billing Considerations

Document the extent of the laceration and any associated injuries to ensure accurate coding.

Coding Guidelines

Inclusion Criteria

Use S01.81 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the code accurately reflects the clinical documentation and that all relevant details are captured

Exclusion Criteria

Do NOT use S01.81 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds of the head

Clinical Scenario

Used when a laceration is repaired in an outpatient setting.

Documentation Requirements

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

Specialty Considerations

Ensure that the procedure aligns with the diagnosis for accurate billing.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of lacerations, improving the granularity of data collection and enhancing the ability to track injury patterns.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of lacerations, improving the granularity of data collection and enhancing the ability to track injury patterns.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of lacerations, improving the granularity of data collection and enhancing the ability to track injury patterns.

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 S01.81 and S01.82?

S01.81 is used for lacerations without foreign bodies, while S01.82 is for lacerations that involve foreign bodies. Accurate documentation is essential to determine which code to use.