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ICD-10 Guide
ICD-10 CodesS61.232

S61.232

Billable

Puncture wound without foreign body of right middle finger without damage to nail

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

Code Description

ICD-10 S61.232 is a billable code used to indicate a diagnosis of puncture wound without foreign body of right middle finger without damage to nail.

Key Diagnostic Point:

A puncture wound of the right middle finger occurs when a sharp object penetrates the skin, creating a small hole without causing damage to the nail or introducing a foreign body. This type of injury is common in various settings, including workplaces, homes, and recreational activities. The wound may vary in depth and can potentially affect underlying structures such as tendons, nerves, and blood vessels. Although the nail remains intact, the injury can lead to complications such as infection, inflammation, or impaired function of the finger. Proper assessment is crucial to determine the extent of the injury and to rule out associated conditions like tendon injuries or nerve damage. Treatment typically involves cleaning the wound, monitoring for signs of infection, and possibly administering a tetanus shot if indicated. In some cases, surgical intervention may be necessary to repair any damaged structures or to ensure proper healing.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between puncture wounds and lacerations
  • Assessing for potential tendon or nerve involvement
  • Determining the need for surgical intervention
  • Documenting the absence of foreign bodies

Audit Risk Factors

  • Inadequate documentation of the injury mechanism
  • Failure to specify the exact location of the wound
  • Lack of follow-up documentation for healing progress
  • Misclassification of the wound type

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Detailed description of the injury mechanism, assessment of associated injuries, and treatment provided.

Common Clinical Scenarios

Patients presenting with puncture wounds from sharp objects, such as nails or knives, often requiring immediate care.

Billing Considerations

Ensure that all relevant structures are assessed and documented to avoid complications.

Orthopedic Surgery

Documentation Requirements

Comprehensive evaluation of potential tendon or nerve damage, surgical notes if intervention is performed.

Common Clinical Scenarios

Patients with puncture wounds requiring surgical repair of underlying structures.

Billing Considerations

Document any surgical findings and post-operative care instructions.

Coding Guidelines

Inclusion Criteria

Use S61.232 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the injury type, location, and any associated conditions

Exclusion Criteria

Do NOT use S61.232 When
  • Exclude codes for injuries with foreign bodies or those involving nail damage

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used for simple repair of the puncture wound if suturing is required.

Documentation Requirements

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

Specialty Considerations

Orthopedic surgeons should document any findings related to underlying structures.

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 puncture wounds, which helps in better tracking and management of hand injuries.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including puncture wounds, which helps in better tracking and management of hand injuries.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of injuries, including puncture wounds, which helps in better tracking and management of hand injuries.

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 puncture wound?

Document the mechanism of injury, the depth of the wound, any associated injuries, treatment provided, and follow-up care instructions.