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ICD-10 Guide
ICD-10 CodesS81.812

S81.812

Billable

Laceration without foreign body, left lower leg

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

Code Description

ICD-10 S81.812 is a billable code used to indicate a diagnosis of laceration without foreign body, left lower leg.

Key Diagnostic Point:

S81.812 refers to a laceration of the left lower leg that does not involve any foreign body. This type of injury typically occurs due to trauma, such as falls, accidents, or sports injuries. The left lower leg encompasses the area from the knee to the ankle, including the tibia and fibula. Lacerations can vary in severity, from superficial cuts affecting only the skin to deeper wounds that may involve underlying tissues, muscles, or tendons. In cases where the laceration is significant, it may lead to complications such as infection, delayed healing, or even the need for surgical intervention. Proper assessment and documentation of the laceration's depth, location, and any associated injuries, such as fractures or ligament tears, are crucial for accurate coding and treatment planning. Additionally, the management of these injuries may involve orthopedic reconstructive procedures, especially if there is damage to the surrounding structures. Understanding the implications of this code is essential for healthcare providers to ensure appropriate treatment and reimbursement.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in laceration severity and depth
  • Potential for associated injuries (fractures, ligament tears)
  • Need for detailed documentation of injury specifics
  • Differentiation from similar codes (e.g., open fractures)

Audit Risk Factors

  • Inadequate documentation of injury specifics
  • Failure to note associated injuries
  • Misclassification of laceration depth
  • Inconsistent coding practices across providers

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Detailed descriptions of the laceration, associated injuries, and treatment plans are essential. Imaging results and surgical notes should be included.

Common Clinical Scenarios

Orthopedic specialists often encounter lacerations with associated fractures or ligament injuries, requiring surgical intervention.

Billing Considerations

Orthopedic documentation must clearly differentiate between lacerations and fractures to ensure accurate coding.

Emergency Medicine

Documentation Requirements

Emergency providers must document the mechanism of injury, initial assessment findings, and any immediate interventions performed.

Common Clinical Scenarios

Common scenarios include trauma cases from falls or accidents where lacerations are assessed and treated in the emergency department.

Billing Considerations

Timely and accurate documentation is critical in emergency settings to support coding and billing.

Coding Guidelines

Inclusion Criteria

Use S81.812 When
  • According to ICD
  • 10 coding guidelines, S81
  • 812 should be used when a laceration is documented without any foreign body present
  • Coders must ensure that the documentation supports the diagnosis and that any associated injuries are also coded appropriately

Exclusion Criteria

Do NOT use S81.812 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

12002CPT Code

Simple repair of laceration, face, ears, eyelids, scalp; 2.5 cm or less

Clinical Scenario

Used for simple laceration repairs in the left lower leg.

Documentation Requirements

Documentation must include the size of the laceration and the method of repair.

Specialty Considerations

Orthopedic specialists may perform more complex repairs requiring additional coding.

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 accuracy of medical records and billing. S81.812 provides clarity in coding lacerations without foreign bodies, which aids in treatment planning and reimbursement.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of lacerations, improving the accuracy of medical records and billing. S81.812 provides clarity in coding lacerations without foreign bodies, which aids in treatment planning and reimbursement.

Reimbursement & Billing Impact

billing. S81.812 provides clarity in coding lacerations without foreign bodies, which aids in treatment planning and reimbursement.

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 S81.812 and S81.811?

S81.812 is used for lacerations without foreign bodies, while S81.811 is for lacerations that involve a foreign body. Accurate documentation is crucial to determine which code to use.