Laceration without foreign body of left shoulder
ICD-10 S41.012 is a billable code used to indicate a diagnosis of laceration without foreign body of left shoulder.
S41.012 refers to a laceration of the left shoulder that does not involve any foreign body. This type of injury typically results from trauma, such as falls, sports injuries, or accidents. The shoulder is a complex joint that includes the humerus, scapula, and clavicle, and is surrounded by muscles, tendons, and ligaments. A laceration in this area can lead to complications such as infection, impaired range of motion, and potential damage to underlying structures, including the rotator cuff. Proper assessment and management are crucial to prevent long-term disability. Treatment may involve wound care, suturing, and possibly physical therapy to restore function. In cases where the laceration is deep, surgical intervention may be necessary to repair damaged tissues. Coders must ensure accurate documentation of the injury's specifics, including the depth and extent of the laceration, to support the use of this code.
Detailed operative notes, including the extent of the laceration and any repairs performed.
Surgical repair of lacerations involving rotator cuff tears or other shoulder structures.
Ensure that all associated procedures are coded accurately to reflect the complexity of the surgical intervention.
Thorough documentation of the initial assessment, treatment provided, and follow-up care instructions.
Management of acute lacerations due to trauma, including wound cleaning and suturing.
Accurate coding of the injury type and any immediate complications that arise during treatment.
Used for suturing a laceration on the left shoulder.
Document the size of the laceration and the method of repair.
Orthopedic surgeons may need to provide additional details on the complexity of the repair.
S41.012 is used for lacerations of the left shoulder without foreign bodies, while S41.011 is for the right shoulder. Accurate coding requires attention to the side of the injury.
