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v1.0.0
ICD-10 Guide
ICD-10 CodesS21.1

S21.1

Billable

Open wound of front wall of thorax without penetration into thoracic cavity

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/23/2025

Code Description

ICD-10 S21.1 is a billable code used to indicate a diagnosis of open wound of front wall of thorax without penetration into thoracic cavity.

Key Diagnostic Point:

An open wound of the front wall of the thorax refers to a laceration or abrasion that affects the skin and underlying tissues of the chest wall but does not extend into the thoracic cavity. This type of injury can occur due to blunt or penetrating trauma, such as from a fall, motor vehicle accident, or stab wound. While the wound may be superficial, it can still pose significant risks, including infection, bleeding, and potential damage to underlying structures such as ribs, muscles, and nerves. It is crucial to assess for associated injuries, such as rib fractures, pneumothorax, or hemothorax, which may complicate the clinical picture. The management of these wounds often involves thorough cleaning, debridement, and sometimes surgical intervention to ensure proper healing and prevent complications. Accurate coding is essential for appropriate treatment reimbursement and tracking of trauma-related injuries.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between open and closed wounds
  • Assessing for associated injuries like rib fractures or pneumothorax
  • Documentation of the extent and depth of the wound
  • Understanding the implications of potential surgical interventions

Audit Risk Factors

  • Inadequate documentation of the wound's size and depth
  • Failure to document associated injuries
  • Misclassification of the wound type (open vs. closed)
  • Inconsistent coding of surgical interventions

Specialty Focus

Medical Specialties

Trauma Surgery

Documentation Requirements

Detailed descriptions of the wound, associated injuries, and surgical interventions performed.

Common Clinical Scenarios

Management of traumatic chest injuries, including lacerations and rib fractures.

Billing Considerations

Ensure accurate coding of any surgical procedures performed in conjunction with wound management.

Emergency Medicine

Documentation Requirements

Comprehensive assessment of the patient's condition, including vital signs and imaging results.

Common Clinical Scenarios

Initial evaluation and stabilization of patients with chest trauma.

Billing Considerations

Document all findings and interventions to support the diagnosis and coding.

Coding Guidelines

Inclusion Criteria

Use S21.1 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the injury's nature and any associated conditions
  • Include details about the mechanism of injury and any surgical procedures performed

Exclusion Criteria

Do NOT use S21.1 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used for repair of the open wound on the chest wall.

Documentation Requirements

Document the size and location of the wound, as well as the repair technique used.

Specialty Considerations

Trauma surgeons should ensure that all associated injuries are documented.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of open wounds, improving the accuracy of data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of open wounds, improving the accuracy of data collection 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 S21.1 and S21.0?

S21.1 refers specifically to open wounds of the thorax, while S21.0 is for closed wounds. Accurate documentation is essential to determine the correct code.