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ICD-10 Guide
ICD-10 CodesS81.80

S81.80

Billable

Unspecified open wound of lower leg

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

Code Description

ICD-10 S81.80 is a billable code used to indicate a diagnosis of unspecified open wound of lower leg.

Key Diagnostic Point:

An unspecified open wound of the lower leg refers to a traumatic injury that results in a break in the skin and underlying tissues of the lower leg, which includes the area between the knee and the ankle. This type of injury can occur due to various mechanisms, such as falls, accidents, or penetrating injuries. The open wound may involve soft tissue damage, exposure of underlying structures, and potential complications such as infection or delayed healing. In the context of knee injuries, tibial or fibular fractures, and ligament tears, the presence of an open wound can complicate the clinical picture, necessitating careful assessment and management. Orthopedic reconstructive procedures may be required to repair the damage, especially if the wound is extensive or involves significant structural compromise. Accurate coding is essential for appropriate treatment planning and reimbursement, as well as for tracking outcomes and complications associated with these injuries.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in the severity and type of open wound
  • Potential for associated fractures or ligament injuries
  • Need for detailed documentation of the injury mechanism
  • Variability in treatment approaches and surgical interventions

Audit Risk Factors

  • Inadequate documentation of the injury mechanism
  • Failure to specify the extent of the wound
  • Lack of clarity regarding associated injuries
  • Inconsistent coding practices among providers

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

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

Common Clinical Scenarios

Open fractures, ligament repairs, and reconstructive surgeries following traumatic injuries.

Billing Considerations

Ensure that all associated injuries are documented to support the coding of S81.80.

Emergency Medicine

Documentation Requirements

Comprehensive assessment of the wound, including size, depth, and any foreign bodies present.

Common Clinical Scenarios

Initial evaluation and management of open wounds, including irrigation and debridement.

Billing Considerations

Document the mechanism of injury and any immediate interventions performed.

Coding Guidelines

Inclusion Criteria

Use S81.80 When
  • Follow official ICD
  • 10 coding guidelines, ensuring that the code is used only when the specific type of open wound is not documented
  • Include additional codes for any associated injuries or complications

Exclusion Criteria

Do NOT use S81.80 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

11042CPT Code

Debridement, open wound

Clinical Scenario

Used for surgical cleaning of an open wound on the lower leg.

Documentation Requirements

Document the extent of debridement and any tissue removed.

Specialty Considerations

Orthopedic surgeons should detail the type of tissue involved.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of open wounds, improving the ability to track and manage these injuries. S81.80 serves as a catch-all for unspecified cases, but coders should strive for specificity when possible.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of open wounds, improving the ability to track and manage these injuries. S81.80 serves as a catch-all for unspecified cases, but coders should strive for specificity when possible.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of open wounds, improving the ability to track and manage these injuries. S81.80 serves as a catch-all for unspecified cases, but coders should strive for specificity when possible.

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

When should I use S81.80?

Use S81.80 when there is an unspecified open wound of the lower leg, and no further details about the type or extent of the wound are available.