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ICD-10 Guide
ICD-10 CodesS61.201

S61.201

Billable

Unspecified open wound of left index finger without damage to nail

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

Code Description

ICD-10 S61.201 is a billable code used to indicate a diagnosis of unspecified open wound of left index finger without damage to nail.

Key Diagnostic Point:

An unspecified open wound of the left index finger without damage to the nail indicates a traumatic injury that has penetrated the skin but does not involve the nail structure. Such wounds can result from various incidents, including cuts, lacerations, or punctures. The clinical presentation may include bleeding, pain, and swelling at the injury site. The absence of nail damage suggests that the injury is limited to the soft tissue, which may involve the dermis and subcutaneous layers. Proper assessment is crucial to rule out deeper injuries, such as tendon or nerve damage, which can occur in more severe cases. Treatment typically involves cleaning the wound, possibly suturing, and monitoring for infection. The management of such injuries is essential to prevent complications and ensure proper healing. Documentation should include the mechanism of injury, the extent of the wound, and any associated symptoms to support accurate coding and treatment planning.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in wound presentation and severity
  • Potential for associated injuries (tendons, nerves)
  • Need for detailed documentation of injury mechanism
  • Differentiation from similar codes for accurate coding

Audit Risk Factors

  • Inadequate documentation of the injury mechanism
  • Failure to specify the extent of the wound
  • Lack of follow-up documentation
  • Inconsistent coding with treatment provided

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Detailed description of the injury, mechanism, and treatment provided.

Common Clinical Scenarios

Patients presenting with hand injuries from accidents, sports, or household incidents.

Billing Considerations

Ensure that all aspects of the injury are documented, including any potential for deeper tissue involvement.

Orthopedic Surgery

Documentation Requirements

Comprehensive assessment of the injury, including imaging if necessary.

Common Clinical Scenarios

Surgical intervention for complex hand injuries or repair of associated tendon injuries.

Billing Considerations

Document any surgical procedures performed and the rationale for intervention.

Coding Guidelines

Inclusion Criteria

Use S61.201 When
  • Follow official coding guidelines for open wounds, ensuring that the documentation supports the use of this code
  • Include details about the injury's mechanism, treatment provided, and any follow
  • up care

Exclusion Criteria

Do NOT use S61.201 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used when the wound is sutured in the emergency department.

Documentation Requirements

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

Specialty Considerations

Emergency medicine providers should ensure accurate coding based on the complexity of 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, improving the accuracy of claims and facilitating better patient care through detailed documentation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, improving the accuracy of claims and facilitating better patient care through detailed documentation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of injuries, improving the accuracy of claims and facilitating better patient care through detailed documentation.

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 to support the use of S61.201?

Document the mechanism of injury, the extent of the wound, any treatment provided, and follow-up care instructions to ensure accurate coding.