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v1.0.0
ICD-10 Guide
ICD-10 CodesS21.90

S21.90

Billable

Unspecified open wound of unspecified part of thorax

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

Code Description

ICD-10 S21.90 is a billable code used to indicate a diagnosis of unspecified open wound of unspecified part of thorax.

Key Diagnostic Point:

An unspecified open wound of the thorax refers to a traumatic injury that results in a break in the skin and underlying tissues in the chest area, without specific details on the exact location or nature of the wound. This type of injury can arise from various mechanisms, including blunt trauma, penetrating injuries, or surgical interventions. Common complications associated with thoracic open wounds include rib fractures, pneumothorax (air in the pleural space), hemothorax (blood in the pleural space), and potential cardiac injuries. The management of these wounds often requires a multidisciplinary approach, including trauma surgery, cardiology, and respiratory therapy. Surgical interventions may involve debridement, chest tube placement, or thoracotomy, depending on the severity and nature of the injury. Accurate coding is crucial for appropriate treatment planning and reimbursement, as well as for tracking outcomes in trauma care.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation of wound specifics
  • Potential for multiple associated injuries (e.g., rib fractures, pneumothorax)
  • Need for precise anatomical localization
  • Differentiation from other thoracic injuries

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to specify associated injuries
  • Lack of clarity on the treatment provided
  • Inconsistent use of terminology in clinical notes

Specialty Focus

Medical Specialties

Trauma Surgery

Documentation Requirements

Detailed descriptions of the injury mechanism, location, and treatment provided.

Common Clinical Scenarios

Management of patients with open thoracic wounds following accidents or falls.

Billing Considerations

Ensure documentation reflects the complexity of associated injuries and interventions.

Emergency Medicine

Documentation Requirements

Accurate recording of initial assessment findings, imaging results, and immediate interventions.

Common Clinical Scenarios

Assessment and stabilization of trauma patients presenting with chest injuries.

Billing Considerations

Document all vital signs and interventions performed in the emergency setting.

Coding Guidelines

Inclusion Criteria

Use S21.90 When
  • Follow official ICD
  • CM coding guidelines, ensuring that the code is used only when the specific site of the wound is not documented
  • Include any associated injuries or complications in the coding process

Exclusion Criteria

Do NOT use S21.90 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

32000CPT Code

Thoracentesis

Clinical Scenario

Used for drainage of pleural effusion in patients with thoracic wounds.

Documentation Requirements

Document indication for procedure, findings, and any complications.

Specialty Considerations

Ensure that the procedure is linked to the diagnosis of an open thoracic wound.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of thoracic injuries, improving the granularity of data for research and reimbursement. However, the unspecified nature of S21.90 may lead to challenges in capturing the full clinical picture.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of thoracic injuries, improving the granularity of data for research and reimbursement. However, the unspecified nature of S21.90 may lead to challenges in capturing the full clinical picture.

Reimbursement & Billing Impact

reimbursement. However, the unspecified nature of S21.90 may lead to challenges in capturing the full clinical picture.

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

When should I use S21.90?

Use S21.90 when there is an open wound of the thorax that is not specified further in the documentation. Ensure that associated injuries are documented and coded appropriately.