Open wound of hand
ICD-10 S61.4 is a billable code used to indicate a diagnosis of open wound of hand.
An open wound of the hand refers to a break in the skin that exposes underlying tissues, which can include muscles, tendons, nerves, and bones. This type of injury can result from various mechanisms, such as lacerations, punctures, or abrasions, often occurring in occupational settings or due to accidents. Open wounds can lead to complications such as infection, delayed healing, and functional impairment. The severity of the wound can vary, with some requiring surgical intervention to repair damaged structures, such as tendons or nerves. In cases where fractures are present, appropriate imaging and evaluation are necessary to determine the extent of the injury. Treatment may involve wound care, immobilization, and possibly surgical repair, depending on the complexity of the injury. Accurate coding is essential for proper reimbursement and to reflect the severity of the injury in the patient's medical record.
Detailed descriptions of the injury, surgical procedures performed, and post-operative care.
Fractures associated with open wounds, tendon repairs, and nerve decompression.
Ensure accurate coding of both the wound and any surgical interventions performed.
Thorough documentation of the mechanism of injury, initial assessment, and treatment provided.
Acute presentations of open wounds, management of infections, and referrals for surgical intervention.
Document all assessments and treatments to support coding for potential complications.
Used for simple lacerations of the hand.
Document the size and location of the wound, and the repair technique used.
Orthopedic surgeons may perform more complex repairs requiring additional coding.
Used when a tendon is repaired due to an open wound.
Detail the tendon involved and the method of repair.
Ensure accurate coding of the tendon and any associated procedures.
An open wound involves a break in the skin that exposes underlying tissues, while a closed wound does not break the skin and may involve bruising or internal damage.
