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ICD-10 Guide
ICD-10 CodesS11.91

S11.91

Billable

Laceration without foreign body of unspecified part of neck

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

Code Description

ICD-10 S11.91 is a billable code used to indicate a diagnosis of laceration without foreign body of unspecified part of neck.

Key Diagnostic Point:

S11.91 refers to a laceration of the neck that does not involve a foreign body and is unspecified in terms of the exact location. Lacerations can occur due to various mechanisms such as sharp objects (knives, glass), blunt trauma, or accidents. The neck is a critical area containing vital structures, including the trachea, esophagus, major blood vessels, and nerves. Therefore, lacerations in this region can lead to significant complications, including hemorrhage, airway compromise, and injury to the cervical spine. The clinical presentation may include bleeding, pain, and swelling. Diagnosis typically involves a thorough physical examination and may require imaging studies to assess for deeper injuries. Management often includes wound cleaning, suturing, and monitoring for complications. In cases of significant injury, surgical intervention may be necessary. Accurate coding is essential for proper reimbursement and tracking of injury patterns in healthcare settings.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Unspecified location can lead to ambiguity in coding.
  • Potential for associated injuries that may require additional codes.
  • Variability in documentation quality across providers.
  • Need for precise clinical details to support coding.

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury.
  • Failure to specify the exact location of the laceration.
  • Misuse of unspecified codes when more specific codes are available.
  • Inconsistent coding practices among different providers.

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Detailed documentation of the mechanism of injury, vital signs, and initial treatment provided.

Common Clinical Scenarios

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

Billing Considerations

Ensure that all relevant details are captured to support the diagnosis and any associated procedures.

Surgery

Documentation Requirements

Operative notes must detail the extent of the laceration, any repairs performed, and post-operative care.

Common Clinical Scenarios

Surgical repair of lacerations requiring sutures or other interventions.

Billing Considerations

Document any complications or additional procedures performed during surgery.

Coding Guidelines

Inclusion Criteria

Use S11.91 When
  • Follow the ICD
  • CM guidelines for coding injuries, ensuring that the code reflects the specific nature of the injury and any associated conditions

Exclusion Criteria

Do NOT use S11.91 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used when performing a simple repair of a laceration on the neck.

Documentation Requirements

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

Specialty Considerations

Emergency and surgical specialties should ensure accurate linkage between the procedure and diagnosis.

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 lacerations, which helps in tracking injury patterns and improving patient care.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including lacerations, which helps in tracking injury patterns and improving patient care.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of injuries, including lacerations, which helps in tracking injury patterns and improving patient care.

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 should I document to support the use of S11.91?

Document the mechanism of injury, the extent of the laceration, any treatment provided, and any follow-up care needed.