Laceration without foreign body, unspecified lower leg
ICD-10 S81.819 is a billable code used to indicate a diagnosis of laceration without foreign body, unspecified lower leg.
S81.819 refers to a laceration of the lower leg that does not involve a foreign body and is unspecified in nature. This code is applicable when a patient presents with a laceration that may involve the skin, subcutaneous tissue, or deeper structures of the lower leg, including the tibia and fibula. Such injuries can occur due to various mechanisms, including falls, accidents, or sports injuries. The clinical presentation may vary from superficial cuts to deeper lacerations that could potentially involve underlying structures such as muscles, tendons, or ligaments. In cases where the laceration is associated with knee injuries, tibial or fibular fractures, or ligament tears, it is crucial to assess the extent of the injury and any associated complications. Orthopedic reconstructive procedures may be necessary if the laceration leads to significant structural damage or if there is a risk of infection or poor healing. Accurate coding requires a thorough understanding of the injury's specifics, including the depth and location of the laceration, as well as any associated injuries that may complicate the clinical picture.
Detailed descriptions of the laceration, associated injuries, and treatment plans are essential.
Fractures associated with lacerations, ligament tears requiring surgical intervention.
Ensure that all associated injuries are documented to support the complexity of the case.
Thorough initial assessment notes, including mechanism of injury and immediate treatment provided.
Acute lacerations from trauma, often requiring urgent care and potential surgical referral.
Document the patient's vital signs and any interventions performed to support the diagnosis.
Used for minor lacerations that do not require extensive repair.
Document the size and location of the laceration, as well as the repair technique used.
Orthopedic specialists may need to document any associated injuries.
S81.819 is used for lacerations without foreign bodies, while S81.818 is for lacerations that involve a foreign body. Accurate coding depends on the presence or absence of foreign materials in the wound.
