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ICD-10 Guide
ICD-10 CodesS61.419

S61.419

Billable

Laceration without foreign body of unspecified hand

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

Code Description

ICD-10 S61.419 is a billable code used to indicate a diagnosis of laceration without foreign body of unspecified hand.

Key Diagnostic Point:

S61.419 refers to a laceration of the hand that does not involve a foreign body and is unspecified in terms of the exact location. Lacerations can occur due to various traumatic events, such as cuts from sharp objects, falls, or accidents. The hand is a complex structure composed of bones, tendons, nerves, and blood vessels, making injuries in this area potentially serious. A laceration may affect not only the skin but also underlying structures, leading to complications such as tendon injuries, nerve damage, or fractures. Proper assessment is crucial to determine the extent of the injury and the appropriate treatment. Surgical intervention may be necessary for deeper lacerations that involve tendons or nerves, and accurate coding is essential for reimbursement and tracking of hand injuries. Documentation should include details about the mechanism of injury, the depth of the laceration, and any associated injuries to ensure comprehensive coding and management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation of injury specifics
  • Potential for associated injuries (tendons, nerves)
  • Need for precise anatomical location description
  • Differentiation from similar codes (e.g., fractures, foreign body presence)

Audit Risk Factors

  • Inadequate documentation of injury specifics
  • Failure to note associated injuries (e.g., tendon, nerve)
  • Incorrect coding of the anatomical site
  • Lack of clarity on the mechanism of injury

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed descriptions of the laceration, associated injuries, and surgical procedures performed.

Common Clinical Scenarios

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

Billing Considerations

Ensure documentation reflects the complexity of the injury and any surgical interventions.

Emergency Medicine

Documentation Requirements

Thorough assessment of the injury, including mechanism, depth, and any immediate interventions.

Common Clinical Scenarios

Acute lacerations presenting in the emergency department.

Billing Considerations

Document all findings and treatments to support coding and billing.

Coding Guidelines

Inclusion Criteria

Use S61.419 When
  • Follow official ICD
  • CM coding guidelines, ensuring accurate documentation of the injury's specifics, including depth and associated injuries

Exclusion Criteria

Do NOT use S61.419 When
  • Exclude codes for lacerations with foreign bodies or those involving specific anatomical sites

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used for lacerations requiring simple closure without deeper involvement.

Documentation Requirements

Document the size and location of the laceration, and the method of repair.

Specialty Considerations

Orthopedic surgeons may need to document additional details if tendon or nerve repair 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 hand injuries, improving the ability to track and manage these conditions effectively. S61.419 provides a clear designation for lacerations without foreign bodies, enhancing clinical documentation and billing accuracy.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of hand injuries, improving the ability to track and manage these conditions effectively. S61.419 provides a clear designation for lacerations without foreign bodies, enhancing clinical documentation and billing accuracy.

Reimbursement & Billing Impact

billing accuracy.

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 laceration to use S61.419?

Document the mechanism of injury, depth of the laceration, any associated injuries, and the treatment provided to ensure accurate coding.