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ICD-10 Guide
ICD-10 CodesS71.03

S71.03

Billable

Puncture wound without foreign body of hip

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

Code Description

ICD-10 S71.03 is a billable code used to indicate a diagnosis of puncture wound without foreign body of hip.

Key Diagnostic Point:

A puncture wound without foreign body of the hip is characterized by a penetrating injury that does not involve the introduction of foreign materials into the body. This type of injury can occur due to various mechanisms, including falls, accidents, or sharp objects. Clinically, puncture wounds can lead to complications such as infection, hematoma formation, or damage to underlying structures, including muscles, tendons, and nerves. In the hip region, the proximity to major blood vessels and nerves necessitates careful evaluation and management. Patients may present with localized pain, swelling, and limited range of motion. Treatment often involves wound care, possible surgical intervention to repair any damage, and monitoring for signs of infection. In cases where the puncture wound is associated with fractures or dislocations, comprehensive orthopedic evaluation is essential to address any concurrent injuries. The management of such injuries may involve orthopedic trauma surgery, especially if there is significant soft tissue damage or if the wound is complicated by fractures of the femur or hip dislocation.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between puncture wounds and other types of wounds (e.g., lacerations, abrasions)
  • Identifying associated injuries such as fractures or dislocations
  • Documenting the absence of foreign bodies accurately
  • Understanding the implications of the injury on surrounding structures

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to specify the absence of foreign bodies
  • Misclassification of the wound type
  • Inconsistent coding of associated injuries

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed descriptions of the injury, treatment plan, and any surgical interventions performed.

Common Clinical Scenarios

Management of puncture wounds in conjunction with hip fractures or dislocations.

Billing Considerations

Ensure that all associated injuries are documented to support the coding of S71.03.

Emergency Medicine

Documentation Requirements

Thorough assessment notes, including vital signs, mechanism of injury, and initial treatment provided.

Common Clinical Scenarios

Patients presenting with acute hip injuries following trauma.

Billing Considerations

Accurate documentation of the injury type and any immediate interventions is crucial for proper coding.

Coding Guidelines

Inclusion Criteria

Use S71.03 When
  • According to ICD
  • 10 coding guidelines, S71
  • 03 should be used when documenting a puncture wound without foreign body of the hip
  • It is essential to ensure that the documentation clearly states the absence of foreign bodies and any associated injuries

Exclusion Criteria

Do NOT use S71.03 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

12001CPT Code

Simple repair of superficial wounds

Clinical Scenario

Used for the repair of a puncture wound without complications.

Documentation Requirements

Document the size and location of the wound, as well as the repair technique used.

Specialty Considerations

Orthopedic surgeons should ensure that any associated injuries are documented.

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. This specificity aids in better tracking of injury types and outcomes, which can improve patient care and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries, including puncture wounds. This specificity aids in better tracking of injury types and outcomes, which can improve patient care and resource allocation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of injuries, including puncture wounds. This specificity aids in better tracking of injury types and outcomes, which can improve patient care and resource allocation.

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 S71.03 and S71.01?

S71.03 is used for puncture wounds without foreign bodies, while S71.01 is for puncture wounds that involve foreign bodies. Accurate documentation is crucial to determine which code to use.