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ICD-10 Guide
ICD-10 CodesS41.12

S41.12

Billable

Laceration with foreign body of upper arm

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

Code Description

ICD-10 S41.12 is a billable code used to indicate a diagnosis of laceration with foreign body of upper arm.

Key Diagnostic Point:

S41.12 refers to a laceration of the upper arm 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 skin and underlying tissues. The upper arm consists of the humerus and surrounding soft tissues, including muscles, nerves, and blood vessels. The presence of a foreign body can complicate the healing process, leading to potential infections, delayed wound healing, or further injury to the underlying structures. Treatment often involves surgical intervention to remove the foreign body, repair any damaged tissues, and ensure proper wound closure. The complexity of this condition is heightened by the need for thorough documentation of the injury mechanism, the type of foreign body, and any associated injuries, such as fractures or nerve damage. Accurate coding is essential for appropriate reimbursement and to reflect the severity of the injury in the patient's medical record.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Presence of foreign body complicates treatment and documentation.
  • Potential for associated injuries (e.g., fractures, nerve damage).
  • Variability in surgical procedures required for removal and repair.
  • Need for detailed documentation of injury mechanism and treatment plan.

Audit Risk Factors

  • Inadequate documentation of the foreign body type and location.
  • Failure to document associated injuries or complications.
  • Insufficient detail on the mechanism of injury.
  • Lack of clarity in surgical notes regarding the procedure performed.

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed operative reports, including descriptions of the foreign body and any associated injuries.

Common Clinical Scenarios

Traumatic injuries from falls, sports injuries, or industrial accidents involving sharp objects.

Billing Considerations

Ensure all relevant details about the foreign body and surgical interventions are documented to support coding.

Emergency Medicine

Documentation Requirements

Thorough initial assessment notes, including mechanism of injury and foreign body identification.

Common Clinical Scenarios

Patients presenting with acute trauma to the upper arm with visible lacerations and foreign bodies.

Billing Considerations

Document the patient's vital signs and any immediate interventions performed.

Coding Guidelines

Inclusion Criteria

Use S41.12 When
  • Follow official ICD
  • CM coding guidelines, ensuring accurate documentation of the injury type, location, and any associated conditions
  • Include details about the foreign body and the treatment provided

Exclusion Criteria

Do NOT use S41.12 When
  • Exclude codes for simple lacerations without foreign bodies

Related ICD-10 Codes

Related CPT Codes

12002CPT Code

Simple repair of laceration, face, ears, eyelids, scalp; 2.5 cm or less

Clinical Scenario

Used for simple laceration repairs without foreign bodies.

Documentation Requirements

Document the size and location of the laceration.

Specialty Considerations

Ensure to differentiate from more complex repairs.

24000CPT Code

Repair of laceration, upper arm

Clinical Scenario

Used for laceration repairs involving foreign bodies.

Documentation Requirements

Detailed operative report including foreign body removal.

Specialty Considerations

Document any associated injuries or complications.

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 those with foreign bodies, which enhances the accuracy of medical records and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including those with foreign bodies, which enhances the accuracy of medical records and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

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 should be documented for a laceration with a foreign body?

Document the mechanism of injury, type and location of the foreign body, associated injuries, and the treatment provided, including any surgical interventions.