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ICD-10 Guide
ICD-10 CodesS81.049

S81.049

Billable

Puncture wound with foreign body, unspecified knee

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/26/2025

Code Description

ICD-10 S81.049 is a billable code used to indicate a diagnosis of puncture wound with foreign body, unspecified knee.

Key Diagnostic Point:

A puncture wound with a foreign body in the knee is a specific type of injury characterized by a breach in the skin and underlying tissues caused by a sharp object that penetrates the knee joint or surrounding structures. This injury can lead to complications such as infection, inflammation, and damage to the ligaments, tendons, or cartilage. The knee is a complex joint that bears significant weight and is crucial for mobility, making injuries in this area particularly impactful. The presence of a foreign body can complicate the healing process and may require surgical intervention to remove the object and repair any associated damage. Common causes of such injuries include accidents involving sharp tools, falls, or sports-related incidents. Clinicians must assess the extent of the injury, including any associated fractures or ligament tears, to determine the appropriate treatment plan, which may involve orthopedic reconstructive procedures to restore function and stability to the knee.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of potential foreign bodies (e.g., metal, glass, wood)
  • Need for detailed documentation of the injury's extent
  • Potential for associated injuries (fractures, ligament tears)
  • Variability in treatment approaches based on foreign body type

Audit Risk Factors

  • Inadequate documentation of the foreign body type
  • Failure to document associated injuries
  • Misclassification of the injury severity
  • Lack of follow-up documentation on treatment outcomes

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed descriptions of the injury, imaging results, and treatment plans.

Common Clinical Scenarios

Surgical removal of foreign bodies, repair of associated ligament tears.

Billing Considerations

Ensure accurate coding of any reconstructive procedures performed.

Emergency Medicine

Documentation Requirements

Immediate assessment notes, imaging, and treatment provided in the emergency setting.

Common Clinical Scenarios

Initial evaluation and management of puncture wounds with foreign bodies.

Billing Considerations

Document the mechanism of injury and any immediate interventions performed.

Coding Guidelines

Inclusion Criteria

Use S81.049 When
  • Follow official ICD
  • 10 coding guidelines, ensuring that the code is used for puncture wounds specifically involving foreign bodies

Exclusion Criteria

Do NOT use S81.049 When
  • Exclude codes for simple lacerations or abrasions without foreign body involvement

Related ICD-10 Codes

Related CPT Codes

20610CPT Code

Arthrocentesis, knee

Clinical Scenario

Used when fluid is aspirated from the knee joint post-injury.

Documentation Requirements

Document the reason for aspiration and findings.

Specialty Considerations

Orthopedic specialists may perform this procedure to assess joint health.

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 with foreign bodies, which helps in better tracking and management of such cases.

ICD-9 vs ICD-10

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

Reimbursement & Billing Impact

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

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 primary focus when coding S81.049?

The primary focus is to document the presence of a foreign body and any associated injuries to ensure accurate coding and appropriate treatment.