Open wound of shoulder
ICD-10 S41.0 is a billable code used to indicate a diagnosis of open wound of shoulder.
An open wound of the shoulder refers to a break in the skin and underlying tissues in the shoulder region, which may involve muscle, tendon, or bone. This type of injury can occur due to trauma, such as falls, sports injuries, or accidents. Open wounds can vary in severity, from superficial lacerations to deep puncture wounds that expose underlying structures. In the context of shoulder injuries, open wounds may be associated with dislocations, fractures of the humerus, or rotator cuff injuries. Surgical intervention is often required to repair the damage, especially if the wound is extensive or if there is a risk of infection. The management of open wounds includes thorough cleaning, debridement, and sometimes suturing or stapling to promote healing. Complications can include infection, delayed healing, and functional impairment of the shoulder joint. Accurate coding is essential for proper reimbursement and to reflect the complexity of the injury and treatment provided.
Detailed operative notes, including the type of repair performed and any associated procedures.
Surgical repair of open shoulder fractures, rotator cuff repairs following traumatic injuries.
Ensure that all associated injuries are documented to support the complexity of the case.
Thorough documentation of the mechanism of injury, initial assessment, and treatment provided.
Management of acute open shoulder wounds due to trauma, including initial wound care and stabilization.
Accurate coding of the injury type and any immediate interventions performed.
Used when a rotator cuff repair is performed due to an open wound.
Operative report detailing the procedure and any associated findings.
Orthopedic surgeons must document the extent of the injury and repair.
An open wound involves a break in the skin, exposing underlying tissues, while a closed wound does not break the skin and may involve bruising or internal damage.
