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v1.0.0
ICD-10 Guide
ICD-10 CodesS11.1

S11.1

Billable

Open wound of thyroid gland

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

Code Description

ICD-10 S11.1 is a billable code used to indicate a diagnosis of open wound of thyroid gland.

Key Diagnostic Point:

An open wound of the thyroid gland typically results from penetrating trauma, such as stab wounds or gunshot injuries, or from surgical interventions that inadvertently damage the gland. The thyroid gland, located in the anterior neck, plays a crucial role in metabolic regulation, and injuries can lead to significant complications, including hemorrhage, airway obstruction, and hormonal imbalances. Clinical presentation may include visible lacerations, swelling, and signs of respiratory distress. Diagnosis involves a thorough physical examination, imaging studies such as ultrasound or CT scans, and laboratory tests to assess thyroid function. Management may require surgical intervention to repair the wound, control bleeding, and prevent infection. Post-operative care is essential to monitor for complications such as hematoma formation or thyroid dysfunction. Accurate coding is vital for appropriate reimbursement and quality of care assessment.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation of the mechanism of injury
  • Need for precise anatomical localization of the wound
  • Potential for associated injuries in the neck region
  • Differentiation from other types of thyroid injuries

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to specify the extent of the wound
  • Lack of clarity on associated injuries
  • Improper linkage between diagnosis and procedure codes

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Documentation must include the mechanism of injury, initial assessment findings, and any immediate interventions performed.

Common Clinical Scenarios

Trauma cases involving stabbings or accidents leading to open wounds in the neck.

Billing Considerations

Ensure that all relevant injuries are documented, including airway management and any life-threatening conditions.

Surgery

Documentation Requirements

Operative reports should detail the surgical approach, findings, and any complications encountered during the procedure.

Common Clinical Scenarios

Surgical repair of an open thyroid wound following trauma or during thyroidectomy.

Billing Considerations

Document any thyroid function tests performed post-operatively to assess for complications.

Coding Guidelines

Inclusion Criteria

Use S11.1 When
  • Follow ICD
  • CM guidelines for coding injuries, ensuring specificity in the documentation of the wound type and mechanism of injury

Exclusion Criteria

Do NOT use S11.1 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

60240CPT Code

Thyroidectomy, total or subtotal

Clinical Scenario

Used in cases where surgical intervention is required for open wounds of the thyroid.

Documentation Requirements

Operative report detailing the procedure and any complications.

Specialty Considerations

Ensure that the surgical approach and findings are clearly documented.

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 wounds of the thyroid gland, improving the accuracy of clinical data and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including open wounds of the thyroid gland, improving the accuracy of clinical data 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 primary mechanism of injury for S11.1?

The primary mechanism of injury for S11.1 is penetrating trauma, such as stab wounds or gunshot injuries, leading to an open wound of the thyroid gland.