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ICD-10 Guide
ICD-10 CodesS61.411

S61.411

Billable

Laceration without foreign body of right hand

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

Code Description

ICD-10 S61.411 is a billable code used to indicate a diagnosis of laceration without foreign body of right hand.

Key Diagnostic Point:

S61.411 refers to a laceration of the right hand that does not involve any foreign body. This type of injury is common in various settings, including workplaces, homes, and recreational activities. Lacerations can vary in depth and severity, potentially affecting not only the skin but also underlying structures such as tendons, nerves, and blood vessels. In the case of a laceration without a foreign body, the primary concern is the risk of infection and the need for proper wound care. Depending on the severity, treatment may involve simple wound closure with sutures or more complex surgical intervention if deeper structures are involved. Accurate documentation of the injury's location, depth, and any associated injuries (such as tendon or nerve damage) is crucial for appropriate coding and treatment planning. The right hand is particularly susceptible to injuries due to its frequent use in daily activities, making it essential for healthcare providers to assess the full extent of the injury to prevent complications and ensure optimal recovery.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in injury severity and depth
  • Potential for associated injuries (tendons, nerves)
  • Need for precise documentation of injury location
  • Differentiation from similar codes (e.g., lacerations with foreign bodies)

Audit Risk Factors

  • Inadequate documentation of injury details
  • Failure to note associated injuries (e.g., tendon or nerve damage)
  • Incorrect coding of laceration depth or severity
  • Misclassification of the hand injury type

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed notes on the extent of the laceration, any associated fractures, and surgical interventions performed.

Common Clinical Scenarios

Lacerations requiring surgical repair, tendon repairs, or nerve exploration.

Billing Considerations

Ensure to document any complications or additional procedures performed during surgery.

Emergency Medicine

Documentation Requirements

Thorough assessment of the laceration, including depth, location, and any immediate treatment provided.

Common Clinical Scenarios

Initial evaluation and treatment of hand lacerations, including wound cleaning and suturing.

Billing Considerations

Document any imaging studies performed to rule out fractures or deeper injuries.

Coding Guidelines

Inclusion Criteria

Use S61.411 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the injury's specifics
  • Include details about the mechanism of injury, treatment provided, and any associated injuries

Exclusion Criteria

Do NOT use S61.411 When
  • Exclude codes for lacerations involving foreign bodies or those that are not specific to the right hand

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used for lacerations requiring simple closure without deeper tissue involvement.

Documentation Requirements

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

Specialty Considerations

Orthopedic surgeons may need to document any additional procedures if tendon repair is required.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of lacerations, improving the ability to capture the complexity of hand injuries. S61.411 provides specificity regarding the location and nature of the injury, which is essential for accurate billing and treatment planning.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of lacerations, improving the ability to capture the complexity of hand injuries. S61.411 provides specificity regarding the location and nature of the injury, which is essential for accurate billing and treatment planning.

Reimbursement & Billing Impact

billing and treatment planning.

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 S61.411 and S61.412?

S61.411 is used for lacerations of the right hand without foreign bodies, while S61.412 is for lacerations of the left hand without foreign bodies. The choice of code depends on the laterality of the injury.