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ICD-10 Guide
ICD-10 CodesS41.119

S41.119

Billable

Laceration without foreign body of unspecified upper arm

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

Code Description

ICD-10 S41.119 is a billable code used to indicate a diagnosis of laceration without foreign body of unspecified upper arm.

Key Diagnostic Point:

S41.119 refers to a laceration of the upper arm that does not involve a foreign body. This injury can occur due to various mechanisms, including trauma from falls, accidents, or sharp objects. The upper arm consists of the humerus bone, muscles, tendons, and nerves, making it susceptible to various injuries. A laceration in this area may affect the skin, subcutaneous tissue, and potentially deeper structures, depending on the severity of the injury. It is crucial to assess the extent of the laceration, as deeper lacerations may involve muscle or nerve damage, which can lead to complications such as impaired mobility or chronic pain. Treatment typically involves cleaning the wound, suturing if necessary, and monitoring for signs of infection. In cases where the laceration is associated with other injuries, such as shoulder dislocations or fractures, comprehensive management is required to address all aspects of the injury. Accurate coding is essential for proper reimbursement and to reflect the complexity of the patient's condition.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation quality
  • Potential for associated injuries (e.g., fractures, dislocations)
  • Differentiation from similar codes (e.g., open fractures)
  • Need for precise anatomical localization

Audit Risk Factors

  • Inadequate documentation of injury specifics
  • Failure to document associated injuries
  • Misclassification of laceration depth
  • Inconsistent coding practices among providers

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed descriptions of the laceration, associated injuries, and treatment provided.

Common Clinical Scenarios

Lacerations occurring during sports injuries, falls, or accidents requiring surgical intervention.

Billing Considerations

Ensure documentation reflects the extent of injury and any surgical repairs performed.

Emergency Medicine

Documentation Requirements

Thorough assessment of the laceration, including depth, location, and any immediate interventions.

Common Clinical Scenarios

Patients presenting with lacerations from accidents or trauma requiring urgent care.

Billing Considerations

Document all findings and treatments to support coding and billing.

Coding Guidelines

Inclusion Criteria

Use S41.119 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the injury's specifics
  • Include details about the mechanism of injury and any associated conditions

Exclusion Criteria

Do NOT use S41.119 When
  • Exclude codes for lacerations with foreign bodies or those involving deeper structures unless specified

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used for lacerations requiring suturing without deeper tissue involvement.

Documentation Requirements

Document the size, location, and depth of the laceration.

Specialty Considerations

Orthopedic surgeons may need to document any associated injuries.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of lacerations, improving the granularity of data collection and reimbursement accuracy. S41.119 provides a clear distinction for lacerations without foreign bodies, which was less defined in ICD-9.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of lacerations, improving the granularity of data collection and reimbursement accuracy. S41.119 provides a clear distinction for lacerations without foreign bodies, which was less defined in ICD-9.

Reimbursement & Billing Impact

reimbursement accuracy. S41.119 provides a clear distinction for lacerations without foreign bodies, which was less defined in ICD-9.

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 S41.119 and S41.11?

S41.119 is used for lacerations without foreign bodies, while S41.11 is for lacerations that involve a foreign body. Accurate documentation is essential to determine which code to use.