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ICD-10 Guide
ICD-10 CodesS61.109

S61.109

Billable

Unspecified open wound of unspecified thumb with damage to nail

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

Code Description

ICD-10 S61.109 is a billable code used to indicate a diagnosis of unspecified open wound of unspecified thumb with damage to nail.

Key Diagnostic Point:

An unspecified open wound of the thumb with damage to the nail indicates a traumatic injury that has penetrated the skin and may involve the nail bed or surrounding soft tissue. This type of injury can occur due to various mechanisms, including lacerations, punctures, or avulsions. The thumb, being a critical digit for hand function, is often subjected to trauma in both occupational and recreational settings. The presence of an open wound suggests a risk of infection, necessitating careful assessment and management. Treatment may involve cleaning the wound, possible suturing, and addressing any damage to the nail or nail bed. Complications can include infection, delayed healing, or permanent nail deformity. Accurate coding is essential for proper treatment reimbursement and tracking of hand injuries, particularly in cases where surgical intervention may be required to repair the nail bed or surrounding structures.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation of wound specifics (depth, location, etc.)
  • Potential for associated injuries (fractures, tendon damage)
  • Need for precise anatomical terminology
  • Differentiation from similar codes for other finger injuries

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to specify the extent of nail damage
  • Misclassification of the wound type (open vs. closed)
  • Lack of follow-up documentation on healing or complications

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed descriptions of the injury, treatment plan, and any surgical interventions performed.

Common Clinical Scenarios

Fractures associated with open wounds, tendon repairs, and nail bed reconstructions.

Billing Considerations

Ensure clarity on the extent of injury and any surgical procedures performed to avoid coding errors.

Emergency Medicine

Documentation Requirements

Thorough assessment of the wound, including size, depth, and any foreign bodies present.

Common Clinical Scenarios

Acute trauma cases presenting with open wounds and potential for infection.

Billing Considerations

Document all interventions performed in the emergency setting, including wound care and referrals.

Coding Guidelines

Inclusion Criteria

Use S61.109 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the code reflects the specific nature of the injury
  • Include any relevant details about the wound's characteristics and associated injuries

Exclusion Criteria

Do NOT use S61.109 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used for repair of the open wound on the thumb.

Documentation Requirements

Document the size and depth of the wound, as well as the repair technique used.

Specialty Considerations

Orthopedic surgeons may perform more complex repairs if tendon or bone is involved.

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 wounds of the thumb. This specificity aids in better tracking of injury patterns and outcomes, improving patient care and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including open wounds of the thumb. This specificity aids in better tracking of injury patterns and outcomes, improving patient care 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 I document for an open wound of the thumb?

Document the mechanism of injury, the size and depth of the wound, any associated injuries, and the treatment provided. Include details about nail damage and any surgical interventions if applicable.