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ICD-10 Guide
ICD-10 CodesS41.05

S41.05

Billable

Open bite of shoulder

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/24/2025

Code Description

ICD-10 S41.05 is a billable code used to indicate a diagnosis of open bite of shoulder.

Key Diagnostic Point:

An open bite of the shoulder refers to a specific type of injury characterized by a laceration or puncture wound that penetrates the skin and underlying tissues of the shoulder region. This injury can occur due to various mechanisms, including animal bites, human bites, or traumatic injuries from sharp objects. The shoulder is a complex joint that includes the humerus, scapula, and clavicle, and injuries in this area can lead to significant functional impairment. Open bites can result in damage to the rotator cuff muscles, tendons, and ligaments, potentially leading to dislocations or fractures of the humerus. The management of open bites typically involves thorough wound cleaning, possible surgical intervention to repair damaged structures, and rehabilitation to restore function. Coders must be aware of the potential complications associated with open bites, such as infection, which may necessitate additional coding for associated conditions. Accurate documentation of the mechanism of injury, the extent of the wound, and any surgical interventions performed is crucial for proper coding and reimbursement.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of potential mechanisms of injury (e.g., animal bites, human bites)
  • Need for detailed documentation of the injury's extent and treatment
  • Potential for associated complications (e.g., infections, fractures)
  • Variability in treatment approaches (e.g., surgical vs. conservative management)

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to document associated injuries or complications
  • Incorrect coding of the type of bite (e.g., open vs. closed)
  • Lack of clarity on the treatment provided

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed operative reports, including descriptions of the injury, surgical procedures performed, and post-operative care.

Common Clinical Scenarios

Management of open bites leading to rotator cuff repair or humeral fracture fixation.

Billing Considerations

Ensure that all surgical interventions are clearly documented to support coding for both the injury and the procedure.

Emergency Medicine

Documentation Requirements

Comprehensive notes on the mechanism of injury, initial assessment, and any immediate interventions performed.

Common Clinical Scenarios

Initial evaluation and treatment of patients presenting with open shoulder bites.

Billing Considerations

Accurate documentation of the patient's condition upon arrival and any changes during treatment is essential.

Coding Guidelines

Inclusion Criteria

Use S41.05 When
  • According to ICD
  • 10 coding guidelines, S41
  • 05 should be used when there is a documented open bite of the shoulder
  • Coders must ensure that the injury is clearly described in the medical record, including the mechanism of injury and any associated complications

Exclusion Criteria

Do NOT use S41.05 When
  • Exclusions include bites that do not penetrate the skin or are classified under different injury codes

Related ICD-10 Codes

Related CPT Codes

23470CPT Code

Repair of rotator cuff

Clinical Scenario

Used when a rotator cuff repair is performed following an open bite injury.

Documentation Requirements

Operative report detailing the extent of the injury and the repair performed.

Specialty Considerations

Orthopedic surgeons must document the specific techniques used in the repair.

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 helps in better tracking of injury types and outcomes, leading to improved 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 helps in better tracking of injury types and outcomes, leading to improved patient care and resource allocation.

Reimbursement & Billing Impact

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

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 an open bite and a closed bite?

An open bite involves a break in the skin, allowing for potential exposure to infection and deeper tissue damage, while a closed bite does not penetrate the skin.