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ICD-10 Guide
ICD-10 CodesS21.95

S21.95

Billable

Open bite of unspecified part of thorax

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

Code Description

ICD-10 S21.95 is a billable code used to indicate a diagnosis of open bite of unspecified part of thorax.

Key Diagnostic Point:

An open bite of the thorax refers to a penetrating injury that disrupts the skin and underlying tissues of the thoracic region, which may involve the ribs, pleura, or even the thoracic cavity. This type of injury can result from various mechanisms, including animal bites, human bites, or traumatic incidents such as accidents. The thorax houses vital organs, including the heart and lungs, making such injuries potentially life-threatening. Complications may include rib fractures, pneumothorax (air in the pleural space), hemothorax (blood in the pleural space), and cardiac injuries. The management of open bites often requires surgical intervention to clean the wound, repair any damaged structures, and prevent infection. In cases where rib fractures occur, careful monitoring for respiratory distress and potential complications is essential. The complexity of treatment and coding for open bites of the thorax is heightened by the need to assess and document any associated injuries or complications, which may require additional codes for accurate representation of the patient's condition.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of potential associated injuries (e.g., rib fractures, pneumothorax)
  • Need for detailed documentation of the mechanism of injury
  • Potential for surgical intervention and its implications for coding
  • Variability in clinical presentation and severity of injuries

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to document associated injuries or complications
  • Misuse of unspecified codes when more specific codes are available
  • Inconsistent coding across different encounters for the same patient

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

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

Common Clinical Scenarios

Patients presenting with open thoracic wounds from bites or trauma, requiring immediate assessment and intervention.

Billing Considerations

Ensure all associated injuries are documented, including any need for imaging studies.

Surgery

Documentation Requirements

Operative reports detailing the surgical procedure, findings, and any complications encountered.

Common Clinical Scenarios

Surgical repair of thoracic injuries, including debridement of bite wounds and management of rib fractures.

Billing Considerations

Accurate coding of surgical procedures performed in conjunction with the open bite injury.

Coding Guidelines

Inclusion Criteria

Use S21.95 When
  • According to ICD
  • 10 guidelines, codes for open bites should be used when the injury is documented as such
  • It is essential to include any associated injuries or complications in the coding process
  • The use of additional codes may be necessary to capture the full extent of the patient's condition

Exclusion Criteria

Do NOT use S21.95 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used for the repair of an open bite wound on the thorax.

Documentation Requirements

Document the size and depth of the wound, as well as the method of repair.

Specialty Considerations

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

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 bites. This specificity aids in better tracking of injury types and outcomes, which can improve patient care and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including open bites. This specificity aids in better tracking of injury types and outcomes, which can improve patient care and resource allocation.

Reimbursement & Billing Impact

reimbursement and to avoid claim denials.

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 S21.95 and S21.91?

S21.95 is used for open bites of the thorax without specifying laterality, while S21.91 specifies an open bite of the right thorax.