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ICD-10 Guide
ICD-10 CodesS41.152

S41.152

Billable

Open bite of left upper arm

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

Code Description

ICD-10 S41.152 is a billable code used to indicate a diagnosis of open bite of left upper arm.

Key Diagnostic Point:

An open bite of the left upper arm refers to a wound characterized by a break in the skin and underlying tissues, resulting from a bite injury. This type of injury can occur due to animal bites, human bites, or accidental trauma. Clinically, it is essential to assess the extent of the injury, including any potential damage to muscles, nerves, and blood vessels. Open bites can lead to complications such as infection, delayed healing, and scarring. Treatment typically involves thorough cleaning of the wound, possible surgical intervention to repair damaged tissues, and antibiotic therapy to prevent infection. In cases where the bite has caused significant trauma, orthopedic evaluation may be necessary to assess for associated injuries such as fractures or dislocations. The management of open bites requires a multidisciplinary approach, often involving orthopedic surgeons, plastic surgeons, and infectious disease specialists, particularly in complex cases. Accurate coding is crucial for appropriate reimbursement and tracking of healthcare outcomes.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of potential associated injuries (e.g., fractures, dislocations)
  • Need for detailed documentation of the injury mechanism
  • Potential for complications such as infections
  • Variability in treatment approaches based on injury severity

Audit Risk Factors

  • Inadequate documentation of the injury mechanism
  • Failure to document associated injuries or complications
  • Incorrect coding of the severity of the bite
  • Lack of follow-up documentation for treatment outcomes

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed operative notes, imaging studies, and follow-up assessments are required to document the extent of injury and treatment provided.

Common Clinical Scenarios

Orthopedic surgeons often encounter cases involving open bites that result in fractures or dislocations requiring surgical repair.

Billing Considerations

Orthopedic documentation must clearly outline the relationship between the bite injury and any orthopedic procedures performed.

Plastic Surgery

Documentation Requirements

Comprehensive documentation of wound care, reconstruction techniques, and aesthetic outcomes is essential.

Common Clinical Scenarios

Plastic surgeons may be involved in the repair of soft tissue defects resulting from open bites, especially in cosmetic areas.

Billing Considerations

Documentation should emphasize the functional and aesthetic implications of the injury and repair.

Coding Guidelines

Inclusion Criteria

Use S41.152 When
  • According to ICD
  • 10 guidelines, S41
  • 152 should be used when there is a documented open bite specifically affecting the left upper arm
  • Coders must ensure that the documentation supports the diagnosis and any associated injuries

Exclusion Criteria

Do NOT use S41.152 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used for the repair of an open bite wound on the left upper arm.

Documentation Requirements

Document the size of the wound and the method of repair.

Specialty Considerations

Orthopedic and plastic surgeons may perform these repairs.

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, which enhances data accuracy and improves patient care tracking.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including open bites, which enhances data accuracy and improves patient care tracking.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of injuries, including open bites, which enhances data accuracy and improves patient care tracking.

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 and underlying tissues, while a closed bite does not penetrate the skin. Open bites are more prone to infection and require different coding.