Laceration with foreign body of shoulder
ICD-10 S41.02 is a billable code used to indicate a diagnosis of laceration with foreign body of shoulder.
S41.02 refers to a laceration of the shoulder that is complicated by the presence of a foreign body. This condition typically arises from traumatic injuries, such as accidents or falls, where sharp objects penetrate the shoulder region. The shoulder is a complex joint that includes the humerus, scapula, and clavicle, and is surrounded by muscles, tendons, and ligaments. The presence of a foreign body can lead to additional complications, including infection, delayed healing, and potential damage to underlying structures such as nerves and blood vessels. In cases of laceration with foreign bodies, careful assessment is required to determine the extent of the injury, the type of foreign material involved, and the need for surgical intervention. Treatment often involves wound cleaning, removal of the foreign body, and possibly surgical repair of any associated injuries, such as rotator cuff tears or fractures of the humerus. Accurate coding is essential for proper reimbursement and to reflect the complexity of the injury and treatment provided.
Detailed operative reports, imaging studies, and notes on the mechanism of injury.
Patients presenting with traumatic shoulder injuries requiring surgical intervention.
Ensure documentation reflects the complexity of the injury and any associated procedures performed.
Thorough initial assessment notes, including mechanism of injury and foreign body identification.
Patients with acute shoulder lacerations due to accidents or falls.
Accurate documentation of the injury's nature and immediate treatment provided is crucial.
Used for simple laceration repairs without foreign bodies.
Document the size and location of the laceration.
Orthopedic surgeons may need to provide additional details on the complexity of the repair.
May be used if joint aspiration is performed due to associated swelling.
Document the reason for aspiration and findings.
Orthopedic specialists should note any findings related to the laceration.
You should document the mechanism of injury, the type of foreign body, any associated injuries, and the treatment provided. Detailed operative notes are crucial if surgical intervention is performed.
