Acute Rehab Hospital Outpatient ICD-10 documentation

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1 Acute Rehab Hospital Outpatient documentation Seven key impacts to documentation 1. Disease or disorder site 2. Acuity and/or status of treatment 3. Etiology, causative agent, or disease type and injury/ poisoning cause, intent, activity at the time of the event and place event occurred 4. Underlying and associated conditions 5. Manifestations 6. Complications or adverse events 7. Supporting info such as lab values or socioeconomic key impacts to documentation Most commonly used diagnoses Name Conductive hearing loss, bilateral Sensorineural hearing loss, bilateral Sensory hearing loss, bilateral Dysphagia, unspecified Encounter for hearing examination following failed hearing screening Feeding difficulties and mismanagement H90.0 Conductive hearing loss, bilateral Hearing Loss H90.11 Conductive hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side H90.12 Conductive hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side H90.3 Sensorineural hearing loss, bilateral H90.3 Sensorineural hearing loss, bilateral Clarify the type of hearing loss o Conductive o Sensorineural o Mixed o Noise-induced hearing loss o Ototoxic Specify the toxic agent (e.g., Carboplatin, Erythromycin, Lasix, etc.) List the laterality (i.e., right, left, or bilateral) Identify when hearing restrictions differ in each ear (e.g., conductive hearing loss, right ear with unrestricted hearing in left ear) State when impacted cerumen is present R13.0 Aphagia Refer to 7 key impacts of R13.10 Dysphagia, unspecified Documentation V72.11 Z Encounter for hearing examination following failed hearing screening R63.3 Feeding difficulties 1

2 Name Multiple and unspecified open wound of lower limb, complicated Multiple and unspecified open wound of lower limb, with tendon involvement Multiple and unspecified open wound of lower limb, without mention of complication Open wound of foot except toe(s) alone, complicated S71.029A Laceration with foreign body, unspecified hip, initial S71.029D Laceration with foreign body, unspecified hip, subsequent S71.029S Laceration with foreign body, unspecified hip, S71.009A Unspecified open wound, unspecified hip, initial S71.009D Unspecified open wound, unspecified hip, subsequent S71.009S Unspecified open wound, unspecified hip, S71.009A Unspecified open wound, unspecified hip, initial S71.009D Unspecified open wound, unspecified hip, subsequent S71.009S Unspecified open wound, unspecified hip, S91.321A Laceration with foreign body, right foot, initial S91.321D Laceration with foreign body, right foot, subsequent S91.321S Laceration with foreign body, right foot, S91.322A Laceration with foreign body, left foot, initial S91.322D Laceration with foreign body, left foot, subsequent S91.322S Laceration with foreign body, left foot, S91.329A Laceration with foreign body, unspecified foot, initial S91.329D Laceration with foreign body, unspecified foot, subsequent S91.329S Laceration with foreign body, unspecified foot, S91.341A Puncture wound with foreign body, right foot, initial S91.341D Puncture wound with foreign body, right foot, subsequent S91.341S Puncture wound with foreign body, right foot, S91.342A Puncture wound with foreign body, left foot, initial S91.342D Puncture wound with foreign body, left foot, subsequent Injuries Identify the specific location and type of injury (e.g. abrasion, laceration, puncture, fracture) Identify the reason for visit (type of ) associated with new or healing injuries (e.g. initial visit for ED, subsequent visit for aftercare and follow-up, (or late effect) visit for treatment of residuals from injury Detail the cause of the injury (e.g. car accident, fall down stairs) Detail child abuse, neglect and other mistreatment o Clarify it as being confirmed, suspected or ruled out Identify the intention or patient mindset (e.g. accidental, assault, self-inflicted, undetermined) surrounding an injury or misadventure Provide the location of the patient when the injury occurred (e.g. school basketball court) List the activity of the patient at the time of the injury (e.g. playing basketball) Indicate the work status of the patient at the time of the injury (e.g. volunteer activity, recreation, school sport) 2

3 Name Open wound of foot except toe(s) alone, with tendon involvement Open wound of foot except toe(s) alone, without mention of complication S91.342S Puncture wound with foreign body, left foot, S91.349A Puncture wound with foreign body, unspecified foot, initial S91.349D Puncture wound with foreign body, unspecified foot, subsequent S91.349S Puncture wound with foreign body, unspecified foot, S91.309A Unspecified open wound, unspecified foot, initial S91.309D Unspecified open wound, unspecified foot, subsequent S91.309S Unspecified open wound, unspecified foot, S96.929A Laceration of unspecified muscle and tendon at ankle and foot level, unspecified foot, initial S96.929D Laceration of unspecified muscle and tendon at ankle and foot level, unspecified foot, subsequent S96.929S Laceration of unspecified muscle and tendon at ankle and foot level, unspecified foot, S91.301A Unspecified open wound, right foot, initial S91.301D Unspecified open wound, right foot, subsequent S91.301S Unspecified open wound, right foot, S91.302A Unspecified open wound, left foot, initial S91.302D Unspecified open wound, left foot, subsequent S91.302S Unspecified open wound, left foot, S91.309A Unspecified open wound, unspecified foot, initial S91.309D Unspecified open wound, unspecified foot, subsequent S91.309S Unspecified open wound, unspecified foot, S91.311A Laceration without foreign body, right foot, initial S91.311D Laceration without foreign body, right foot, subsequent S91.311S Laceration without foreign body, right foot, S91.312A Laceration without foreign body, left foot, initial 3

4 Name S91.312D Laceration without foreign body, left foot, subsequent S91.312S Laceration without foreign body, left foot, S91.319A Laceration without foreign body, unspecified foot, initial S91.319D Laceration without foreign body, unspecified foot, subsequent S91.319S Laceration without foreign body, unspecified foot, S91.331A right foot, initial S91.331D right foot, subsequent S91.331S right foot, S91.332A left foot, initial S91.332D left foot, subsequent S91.332S left foot, S91.339A unspecified foot, initial S91.339D unspecified foot, subsequent S91.339S unspecified foot, S91.351A Open bite, right foot, initial S91.351D Open bite, right foot, subsequent S91.351S Open bite, right foot, S91.352A Open bite, left foot, initial S91.352D Open bite, left foot, subsequent S91.352S Open bite, left foot, S91.359A Open bite, unspecified foot, initial S91.359D Open bite, unspecified foot, subsequent S91.359S Open bite, unspecified foot, Open wound of hip and thigh, complicated S71.021A S71.021D Laceration with foreign body, right hip, initial Laceration with foreign body, right hip, subsequent S71.021S Laceration with foreign body, right hip, 4

5 Name S71.022A Laceration with foreign body, left hip, initial S71.022D Laceration with foreign body, left hip, subsequent S71.022S Laceration with foreign body, left hip, S71.029A Laceration with foreign body, unspecified hip, initial S71.029D Laceration with foreign body, unspecified hip, subsequent S71.029S Laceration with foreign body, unspecified hip, S71.041A Puncture wound with foreign body, right hip, initial S71.041D Puncture wound with foreign body, right hip, subsequent S71.041S Puncture wound with foreign body, right hip, S71.042A Puncture wound with foreign body, left hip, initial S71.042D Puncture wound with foreign body, left hip, subsequent S71.042S Puncture wound with foreign body, left hip, S71.049A Puncture wound with foreign body, unspecified hip, initial S71.049D Puncture wound with foreign body, unspecified hip, subsequent S71.049S Puncture wound with foreign body, unspecified hip, S71.121A Laceration with foreign body, right thigh, initial S71.121D Laceration with foreign body, right thigh, subsequent S71.121S Laceration with foreign body, right thigh, S71.122A Laceration with foreign body, left thigh, initial S71.122D Laceration with foreign body, left thigh, subsequent S71.122S Laceration with foreign body, left thigh, S71.129A Laceration with foreign body, unspecified thigh, initial S71.129D Laceration with foreign body, unspecified thigh, subsequent S71.129S Laceration with foreign body, unspecified thigh, 5

6 Name S71.141A Puncture wound with foreign body, right thigh, initial S71.141D Puncture wound with foreign body, right thigh, subsequent S71.141S Puncture wound with foreign body, right thigh, S71.142A Puncture wound with foreign body, left thigh, initial S71.142D Puncture wound with foreign body, left thigh, subsequent S71.142S Puncture wound with foreign body, left thigh, S71.149A Puncture wound with foreign body, unspecified thigh, initial S71.149D Puncture wound with foreign body, unspecified thigh, subsequent S71.149S Puncture wound with foreign body, unspecified thigh, Open wound of hip and thigh, with tendon involvement S71.009A S71.009D Unspecified open wound, unspecified hip, initial Unspecified open wound, unspecified hip, subsequent S71.009S Unspecified open wound, unspecified hip, S71.109A Unspecified open wound, unspecified thigh, initial S71.109D Unspecified open wound, unspecified thigh, subsequent S71.109S Unspecified open wound, unspecified thigh, S76.021A Laceration of muscle, fascia and tendon of right hip, initial S76.021D Laceration of muscle, fascia and tendon of right hip, subsequent S76.021S Laceration of muscle, fascia and tendon of right hip, S76.022A Laceration of muscle, fascia and tendon of left hip, initial S76.022D Laceration of muscle, fascia and tendon of left hip, subsequent S76.022S Laceration of muscle, fascia and tendon of left hip, S76.029A Laceration of muscle, fascia and tendon of unspecified hip, initial S76.029D Laceration of muscle, fascia and tendon of unspecified hip, subsequent S76.029S Laceration of muscle, fascia and tendon of unspecified hip, 6

7 Name S76.121A Laceration of right quadriceps muscle, fascia and tendon, initial S76.121D Laceration of right quadriceps muscle, fascia and tendon, subsequent S76.121S Laceration of right quadriceps muscle, fascia and tendon, S76.122A Laceration of left quadriceps muscle, fascia and tendon, initial S76.122D Laceration of left quadriceps muscle, fascia and tendon, subsequent S76.122S Laceration of left quadriceps muscle, fascia and tendon, S76.129A Laceration of unspecified quadriceps muscle, fascia and tendon, initial S76.129D Laceration of unspecified quadriceps muscle, fascia and tendon, subsequent S76.129S Laceration of unspecified quadriceps muscle, fascia and tendon, S76.221A Laceration of adductor muscle, fascia and tendon of right thigh, initial S76.221D Laceration of adductor muscle, fascia and tendon of right thigh, subsequent S76.221S Laceration of adductor muscle, fascia and tendon of right thigh, S76.222A Laceration of adductor muscle, fascia and tendon of left thigh, initial S76.222D Laceration of adductor muscle, fascia and tendon of left thigh, subsequent S76.222S Laceration of adductor muscle, fascia and tendon of left thigh, S76.229A Laceration of adductor muscle, fascia and tendon of unspecified thigh, initial S76.229D Laceration of adductor muscle, fascia and tendon of unspecified thigh, subsequent S76.229S Laceration of adductor muscle, fascia and tendon of unspecified thigh, S76.321A Laceration of muscle, fascia and tendon of the posterior muscle group at thigh level, right thigh, initial S76.321D Laceration of muscle, fascia and tendon of the posterior muscle group at thigh level, right thigh, subsequent 7

8 Name S76.321S Laceration of muscle, fascia and tendon of the posterior muscle group at thigh level, right thigh, S76.322A Laceration of muscle, fascia and tendon of the posterior muscle group at thigh level, left thigh, initial S76.322D Laceration of muscle, fascia and tendon of the posterior muscle group at thigh level, left thigh, subsequent S76.322S Laceration of muscle, fascia and tendon of the posterior muscle group at thigh level, left thigh, S76.329A Laceration of muscle, fascia and tendon of the posterior muscle group at thigh level, unspecified thigh, initial S76.329D Laceration of muscle, fascia and tendon of the posterior muscle group at thigh level, unspecified thigh, subsequent S76.329S Laceration of muscle, fascia and tendon of the posterior muscle group at thigh level, unspecified thigh, S76.821A Laceration of other specified muscles, fascia and tendons at thigh level, right thigh, initial S76.821D Laceration of other specified muscles, fascia and tendons at thigh level, right thigh, subsequent S76.821S Laceration of other specified muscles, fascia and tendons at thigh level, right thigh, S76.822A Laceration of other specified muscles, fascia and tendons at thigh level, left thigh, initial S76.822D Laceration of other specified muscles, fascia and tendons at thigh level, left thigh, subsequent S76.822S Laceration of other specified muscles, fascia and tendons at thigh level, left thigh, S76.829A Laceration of other specified muscles, fascia and tendons at thigh level, unspecified thigh, initial S76.829D Laceration of other specified muscles, fascia and tendons at thigh level, unspecified thigh, subsequent S76.829S Laceration of other specified muscles, fascia and tendons at thigh level, unspecified thigh, S76.921A Laceration of unspecified muscles, fascia and tendons at thigh level, right thigh, initial 8

9 Name S76.921D Laceration of unspecified muscles, fascia and tendons at thigh level, right thigh, subsequent S76.921S Laceration of unspecified muscles, fascia and tendons at thigh level, right thigh, S76.922A Laceration of unspecified muscles, fascia and tendons at thigh level, left thigh, initial S76.922D Laceration of unspecified muscles, fascia and tendons at thigh level, left thigh, subsequent S76.922S Laceration of unspecified muscles, fascia and tendons at thigh level, left thigh, S76.929A Laceration of unspecified muscles, fascia and tendons at thigh level, unspecified thigh, initial S76.929D Laceration of unspecified muscles, fascia and tendons at thigh level, unspecified thigh, subsequent S76.929S Laceration of unspecified muscles, fascia and tendons at thigh level, unspecified thigh, Open wound of hip and thigh, without mention of complication S71.001A S71.001D Unspecified open wound, right hip, initial Unspecified open wound, right hip, subsequent S71.001S Unspecified open wound, right hip, S71.002A Unspecified open wound, left hip, initial S71.002D Unspecified open wound, left hip, subsequent S71.002S Unspecified open wound, left hip, S71.009A Unspecified open wound, unspecified hip, initial S71.009D Unspecified open wound, unspecified hip, subsequent S71.009S Unspecified open wound, unspecified hip, S71.011A Laceration without foreign body, right hip, initial S71.011D Laceration without foreign body, right hip, subsequent S71.011S Laceration without foreign body, right hip, S71.012A Laceration without foreign body, left hip, initial 9

10 Name S71.012D Laceration without foreign body, left hip, subsequent S71.012S Laceration without foreign body, left hip, S71.019A Laceration without foreign body, unspecified hip, initial S71.019D Laceration without foreign body, unspecified hip, subsequent S71.019S Laceration without foreign body, unspecified hip, S71.031A right hip, initial S71.031D right hip, subsequent S71.031S right hip, S71.032A left hip, initial S71.032D left hip, subsequent S71.032S left hip, S71.039A unspecified hip, initial S71.039D unspecified hip, subsequent S71.039S unspecified hip, S71.051A Open bite, right hip, initial S71.051D Open bite, right hip, subsequent S71.051S Open bite, right hip, S71.052A Open bite, left hip, initial S71.052D Open bite, left hip, subsequent S71.052S Open bite, left hip, S71.059A Open bite, unspecified hip, initial S71.059D Open bite, unspecified hip, subsequent S71.059S Open bite, unspecified hip, S71.101A Unspecified open wound, right thigh, initial S71.101D Unspecified open wound, right thigh, subsequent S71.101S Unspecified open wound, right thigh, S71.102A Unspecified open wound, left thigh, initial 10

11 Name S71.102D Unspecified open wound, left thigh, subsequent S71.102S Unspecified open wound, left thigh, S71.109A Unspecified open wound, unspecified thigh, initial S71.109D Unspecified open wound, unspecified thigh, subsequent S71.109S Unspecified open wound, unspecified thigh, S71.111A Laceration without foreign body, right thigh, initial S71.111D Laceration without foreign body, right thigh, subsequent S71.111S Laceration without foreign body, right thigh, S71.112A Laceration without foreign body, left thigh, initial S71.112D Laceration without foreign body, left thigh, subsequent S71.112S Laceration without foreign body, left thigh, S71.119A Laceration without foreign body, unspecified thigh, initial S71.119D Laceration without foreign body, unspecified thigh, subsequent S71.119S Laceration without foreign body, unspecified thigh, S71.131A right thigh, initial S71.131D right thigh, subsequent S71.131S right thigh, S71.132A left thigh, initial S71.132D left thigh, subsequent S71.132S left thigh, S71.139A unspecified thigh, initial S71.139D unspecified thigh, subsequent S71.139S unspecified thigh, S71.151A Open bite, right thigh, initial S71.151D Open bite, right thigh, subsequent S71.151S Open bite, right thigh, 11

12 Name S71.152A Open bite, left thigh, initial S71.152D Open bite, left thigh, subsequent S71.152S Open bite, left thigh, S71.159A Open bite, unspecified thigh, initial S71.159D Open bite, unspecified thigh, subsequent S71.159S Open bite, unspecified thigh, Open wound of knee, leg [except thigh], and ankle, complicated S81.021A S81.021D Laceration with foreign body, right knee, initial Laceration with foreign body, right knee, subsequent S81.021S Laceration with foreign body, right knee, S81.022A Laceration with foreign body, left knee, initial S81.022D Laceration with foreign body, left knee, subsequent S81.022S Laceration with foreign body, left knee, S81.029A Laceration with foreign body, unspecified knee, initial S81.029D Laceration with foreign body, unspecified knee, subsequent S81.029S Laceration with foreign body, unspecified knee, S81.041A Puncture wound with foreign body, right knee, initial S81.041D Puncture wound with foreign body, right knee, subsequent S81.041S Puncture wound with foreign body, right knee, S81.042A Puncture wound with foreign body, left knee, initial S81.042D Puncture wound with foreign body, left knee, subsequent S81.042S Puncture wound with foreign body, left knee, S81.049A Puncture wound with foreign body, unspecified knee, initial S81.049D Puncture wound with foreign body, unspecified knee, subsequent S81.049S Puncture wound with foreign body, unspecified knee, S81.821A Laceration with foreign body, right lower leg, initial S81.821D Laceration with foreign body, right lower leg, subsequent 12

13 Name S81.821S Laceration with foreign body, right lower leg, S81.822A Laceration with foreign body, left lower leg, initial S81.822D Laceration with foreign body, left lower leg, subsequent S81.822S Laceration with foreign body, left lower leg, S81.829A Laceration with foreign body, unspecified lower leg, initial S81.829D Laceration with foreign body, unspecified lower leg, subsequent S81.829S Laceration with foreign body, unspecified lower leg, S81.841A Puncture wound with foreign body, right lower leg, initial S81.841D Puncture wound with foreign body, right lower leg, subsequent S81.841S Puncture wound with foreign body, right lower leg, S81.842A Puncture wound with foreign body, left lower leg, initial S81.842D Puncture wound with foreign body, left lower leg, subsequent S81.842S Puncture wound with foreign body, left lower leg, S81.849A Puncture wound with foreign body, unspecified lower leg, initial S81.849D Puncture wound with foreign body, unspecified lower leg, subsequent S81.849S Puncture wound with foreign body, unspecified lower leg, S91.021A Laceration with foreign body, right ankle, initial S91.021D Laceration with foreign body, right ankle, subsequent S91.021S Laceration with foreign body, right ankle, S91.022A Laceration with foreign body, left ankle, initial S91.022D Laceration with foreign body, left ankle, subsequent S91.022S Laceration with foreign body, left ankle, S91.029A Laceration with foreign body, unspecified ankle, initial S91.029D Laceration with foreign body, unspecified ankle, subsequent 13

14 Name S91.029S Laceration with foreign body, unspecified ankle, S91.041A Puncture wound with foreign body, right ankle, initial S91.041D Puncture wound with foreign body, right ankle, subsequent S91.041S Puncture wound with foreign body, right ankle, S91.042A Puncture wound with foreign body, left ankle, initial S91.042D Puncture wound with foreign body, left ankle, subsequent S91.042S Puncture wound with foreign body, left ankle, S91.049A Puncture wound with foreign body, unspecified ankle, initial S91.049D Puncture wound with foreign body, unspecified ankle, subsequent S91.049S Puncture wound with foreign body, unspecified ankle, Open wound of knee, leg [except thigh], and ankle, with tendon involvement S81.009A S81.009D S81.009S Unspecified open wound, unspecified knee, initial Unspecified open wound, unspecified knee, subsequent Unspecified open wound, unspecified knee, S81.809A Unspecified open wound, unspecified lower leg, initial S81.809D Unspecified open wound, unspecified lower leg, subsequent S81.809S Unspecified open wound, unspecified lower leg, S86.021A Laceration of right Achilles tendon, initial S86.021D Laceration of right Achilles tendon, subsequent S86.021S Laceration of right Achilles tendon, S86.022A Laceration of left Achilles tendon, initial S86.022D Laceration of left Achilles tendon, subsequent S86.022S Laceration of left Achilles tendon, S86.029A Laceration of unspecified Achilles tendon, initial S86.029D Laceration of unspecified Achilles tendon, subsequent 14

15 Name S86.029S Laceration of unspecified Achilles tendon, S86.121A Laceration of other muscle(s) and tendon(s) of posterior muscle group at lower leg level, right leg, initial S86.121D Laceration of other muscle(s) and tendon(s) of posterior muscle group at lower leg level, right leg, subsequent S86.121S Laceration of other muscle(s) and tendon(s) of posterior muscle group at lower leg level, right leg, S86.122A Laceration of other muscle(s) and tendon(s) of posterior muscle group at lower leg level, left leg, initial S86.122D Laceration of other muscle(s) and tendon(s) of posterior muscle group at lower leg level, left leg, subsequent S86.122S Laceration of other muscle(s) and tendon(s) of posterior muscle group at lower leg level, left leg, S86.129A Laceration of other muscle(s) and tendon(s) of posterior muscle group at lower leg level, unspecified leg, initial S86.129D Laceration of other muscle(s) and tendon(s) of posterior muscle group at lower leg level, unspecified leg, subsequent S86.129S Laceration of other muscle(s) and tendon(s) of posterior muscle group at lower leg level, unspecified leg, S86.221A Laceration of muscle(s) and tendon(s) of anterior muscle group at lower leg level, right leg, initial S86.221D Laceration of muscle(s) and tendon(s) of anterior muscle group at lower leg level, right leg, subsequent S86.221S Laceration of muscle(s) and tendon(s) of anterior muscle group at lower leg level, right leg, S86.222A Laceration of muscle(s) and tendon(s) of anterior muscle group at lower leg level, left leg, initial S86.222D Laceration of muscle(s) and tendon(s) of anterior muscle group at lower leg level, left leg, subsequent S86.222S Laceration of muscle(s) and tendon(s) of anterior muscle group at lower leg level, left leg, 15

16 Name S86.229A Laceration of muscle(s) and tendon(s) of anterior muscle group at lower leg level, unspecified leg, initial S86.229D Laceration of muscle(s) and tendon(s) of anterior muscle group at lower leg level, unspecified leg, subsequent S86.229S Laceration of muscle(s) and tendon(s) of anterior muscle group at lower leg level, unspecified leg, S86.321A Laceration of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, right leg, initial S86.321D Laceration of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, right leg, subsequent S86.321S Laceration of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, right leg, S86.322A Laceration of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, left leg, initial S86.322D Laceration of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, left leg, subsequent S86.322S Laceration of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, left leg, S86.329A Laceration of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, unspecified leg, initial S86.329D Laceration of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, unspecified leg, subsequent S86.329S Laceration of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, unspecified leg, S86.821A Laceration of other muscle(s) and tendon(s) at lower leg level, right leg, initial S86.821D Laceration of other muscle(s) and tendon(s) at lower leg level, right leg, subsequent S86.821S Laceration of other muscle(s) and tendon(s) at lower leg level, right leg, S86.822A Laceration of other muscle(s) and tendon(s) at lower leg level, left leg, initial S86.822D Laceration of other muscle(s) and tendon(s) at lower leg level, left leg, subsequent 16

17 Name S86.822S Laceration of other muscle(s) and tendon(s) at lower leg level, left leg, S86.829A Laceration of other muscle(s) and tendon(s) at lower leg level, unspecified leg, initial S86.829D Laceration of other muscle(s) and tendon(s) at lower leg level, unspecified leg, subsequent S86.829S Laceration of other muscle(s) and tendon(s) at lower leg level, unspecified leg, S86.921A Laceration of unspecified muscle(s) and tendon(s) at lower leg level, right leg, initial S86.921D Laceration of unspecified muscle(s) and tendon(s) at lower leg level, right leg, subsequent S86.921S Laceration of unspecified muscle(s) and tendon(s) at lower leg level, right leg, S86.922A Laceration of unspecified muscle(s) and tendon(s) at lower leg level, left leg, initial S86.922D Laceration of unspecified muscle(s) and tendon(s) at lower leg level, left leg, subsequent S86.922S Laceration of unspecified muscle(s) and tendon(s) at lower leg level, left leg, S86.929A Laceration of unspecified muscle(s) and tendon(s) at lower leg level, unspecified leg, initial S86.929D Laceration of unspecified muscle(s) and tendon(s) at lower leg level, unspecified leg, subsequent S86.929S Laceration of unspecified muscle(s) and tendon(s) at lower leg level, unspecified leg, S91.009A Unspecified open wound, unspecified ankle, initial S91.009D Unspecified open wound, unspecified ankle, subsequent S91.009S Unspecified open wound, unspecified ankle, S96.021A Laceration of muscle and tendon of long flexor muscle of toe at ankle and foot level, right foot, initial S96.021D Laceration of muscle and tendon of long flexor muscle of toe at ankle and foot level, right foot, subsequent 17

18 Name S96.021S Laceration of muscle and tendon of long flexor muscle of toe at ankle and foot level, right foot, S96.022A Laceration of muscle and tendon of long flexor muscle of toe at ankle and foot level, left foot, initial S96.022D Laceration of muscle and tendon of long flexor muscle of toe at ankle and foot level, left foot, subsequent S96.022S Laceration of muscle and tendon of long flexor muscle of toe at ankle and foot level, left foot, S96.029A Laceration of muscle and tendon of long flexor muscle of toe at ankle and foot level, unspecified foot, initial S96.029D Laceration of muscle and tendon of long flexor muscle of toe at ankle and foot level, unspecified foot, subsequent S96.029S Laceration of muscle and tendon of long flexor muscle of toe at ankle and foot level, unspecified foot, S96.121A Laceration of muscle and tendon of long extensor muscle of toe at ankle and foot level, right foot, initial S96.121D Laceration of muscle and tendon of long extensor muscle of toe at ankle and foot level, right foot, subsequent S96.121S Laceration of muscle and tendon of long extensor muscle of toe at ankle and foot level, right foot, S96.122A Laceration of muscle and tendon of long extensor muscle of toe at ankle and foot level, left foot, initial S96.122D Laceration of muscle and tendon of long extensor muscle of toe at ankle and foot level, left foot, subsequent S96.122S Laceration of muscle and tendon of long extensor muscle of toe at ankle and foot level, left foot, S96.129A Laceration of muscle and tendon of long extensor muscle of toe at ankle and foot level, unspecified foot, initial S96.129D Laceration of muscle and tendon of long extensor muscle of toe at ankle and foot level, unspecified foot, subsequent S96.129S Laceration of muscle and tendon of long extensor muscle of toe at ankle and foot level, unspecified foot, S96.221A Laceration of intrinsic muscle and tendon at ankle and foot level, right foot, initial 18

19 Name S96.221D Laceration of intrinsic muscle and tendon at ankle and foot level, right foot, subsequent S96.221S Laceration of intrinsic muscle and tendon at ankle and foot level, right foot, S96.222A Laceration of intrinsic muscle and tendon at ankle and foot level, left foot, initial S96.222D Laceration of intrinsic muscle and tendon at ankle and foot level, left foot, subsequent S96.222S Laceration of intrinsic muscle and tendon at ankle and foot level, left foot, S96.229A Laceration of intrinsic muscle and tendon at ankle and foot level, unspecified foot, initial S96.229D Laceration of intrinsic muscle and tendon at ankle and foot level, unspecified foot, subsequent S96.229S Laceration of intrinsic muscle and tendon at ankle and foot level, unspecified foot, S96.821A Laceration of other specified muscles and tendons at ankle and foot level, right foot, initial S96.821D Laceration of other specified muscles and tendons at ankle and foot level, right foot, subsequent S96.821S Laceration of other specified muscles and tendons at ankle and foot level, right foot, S96.822A Laceration of other specified muscles and tendons at ankle and foot level, left foot, initial S96.822D Laceration of other specified muscles and tendons at ankle and foot level, left foot, subsequent S96.822S Laceration of other specified muscles and tendons at ankle and foot level, left foot, S96.829A Laceration of other specified muscles and tendons at ankle and foot level, unspecified foot, initial S96.829D Laceration of other specified muscles and tendons at ankle and foot level, unspecified foot, subsequent S96.829S Laceration of other specified muscles and tendons at ankle and foot level, unspecified foot, S96.921A Laceration of unspecified muscle and tendon at ankle and foot level, right foot, initial 19

20 Name Open wound of knee, leg [except thigh], and ankle, without mention of complication S96.921D Laceration of unspecified muscle and tendon at ankle and foot level, right foot, subsequent S96.921S Laceration of unspecified muscle and tendon at ankle and foot level, right foot, S96.922A Laceration of unspecified muscle and tendon at ankle and foot level, left foot, initial S96.922D Laceration of unspecified muscle and tendon at ankle and foot level, left foot, subsequent S96.922S Laceration of unspecified muscle and tendon at ankle and foot level, left foot, S96.929A Laceration of unspecified muscle and tendon at ankle and foot level, unspecified foot, initial S96.929D Laceration of unspecified muscle and tendon at ankle and foot level, unspecified foot, subsequent S96.929S Laceration of unspecified muscle and tendon at ankle and foot level, unspecified foot, S81.001A Unspecified open wound, right knee, initial S81.001D Unspecified open wound, right knee, subsequent S81.001S Unspecified open wound, right knee, S81.002A Unspecified open wound, left knee, initial S81.002D Unspecified open wound, left knee, subsequent S81.002S Unspecified open wound, left knee, S81.009A Unspecified open wound, unspecified knee, initial S81.009D Unspecified open wound, unspecified knee, subsequent S81.009S Unspecified open wound, unspecified knee, S81.011A Laceration without foreign body, right knee, initial S81.011D Laceration without foreign body, right knee, subsequent S81.011S Laceration without foreign body, right knee, S81.012A Laceration without foreign body, left knee, initial 20

21 Name S81.012D Laceration without foreign body, left knee, subsequent S81.012S Laceration without foreign body, left knee, S81.019A Laceration without foreign body, unspecified knee, initial S81.019D Laceration without foreign body, unspecified knee, subsequent S81.019S Laceration without foreign body, unspecified knee, S81.031A right knee, initial S81.031D right knee, subsequent S81.031S right knee, S81.032A left knee, initial S81.032D left knee, subsequent S81.032S left knee, S81.039A unspecified knee, initial S81.039D unspecified knee, subsequent S81.039S unspecified knee, S81.051A Open bite, right knee, initial S81.051D Open bite, right knee, subsequent S81.051S Open bite, right knee, S81.052A Open bite, left knee, initial S81.052D Open bite, left knee, subsequent S81.052S Open bite, left knee, S81.059A Open bite, unspecified knee, initial S81.059D Open bite, unspecified knee, subsequent S81.059S Open bite, unspecified knee, S81.801A Unspecified open wound, right lower leg, initial S81.801D Unspecified open wound, right lower leg, subsequent S81.801S Unspecified open wound, right lower leg, S81.802A Unspecified open wound, left lower leg, initial 21

22 Name S81.802D Unspecified open wound, left lower leg, subsequent S81.802S Unspecified open wound, left lower leg, S81.809A Unspecified open wound, unspecified lower leg, initial S81.809D Unspecified open wound, unspecified lower leg, subsequent S81.809S Unspecified open wound, unspecified lower leg, S81.811A Laceration without foreign body, right lower leg, initial S81.811D Laceration without foreign body, right lower leg, subsequent S81.811S Laceration without foreign body, right lower leg, S81.812A Laceration without foreign body, left lower leg, initial S81.812D Laceration without foreign body, left lower leg, subsequent S81.812S Laceration without foreign body, left lower leg, S81.819A Laceration without foreign body, unspecified lower leg, initial S81.819D Laceration without foreign body, unspecified lower leg, subsequent S81.819S Laceration without foreign body, unspecified lower leg, S81.831A right lower leg, initial S81.831D right lower leg, subsequent S81.831S right lower leg, S81.832A left lower leg, initial S81.832D left lower leg, subsequent S81.832S left lower leg, S81.839A unspecified lower leg, initial S81.839D unspecified lower leg, subsequent S81.839S unspecified lower leg, S81.851A Open bite, right lower leg, initial 22

23 Name S81.851D Open bite, right lower leg, subsequent S81.851S Open bite, right lower leg, S81.852A Open bite, left lower leg, initial S81.852D Open bite, left lower leg, subsequent S81.852S Open bite, left lower leg, S81.859A Open bite, unspecified lower leg, initial S81.859D Open bite, unspecified lower leg, subsequent S81.859S Open bite, unspecified lower leg, S91.001A Unspecified open wound, right ankle, initial S91.001D Unspecified open wound, right ankle, subsequent S91.001S Unspecified open wound, right ankle, S91.002A Unspecified open wound, left ankle, initial S91.002D Unspecified open wound, left ankle, subsequent S91.002S Unspecified open wound, left ankle, S91.009A Unspecified open wound, unspecified ankle, initial S91.009D Unspecified open wound, unspecified ankle, subsequent S91.009S Unspecified open wound, unspecified ankle, S91.011A Laceration without foreign body, right ankle, initial S91.011D Laceration without foreign body, right ankle, subsequent S91.011S Laceration without foreign body, right ankle, S91.012A Laceration without foreign body, left ankle, initial S91.012D Laceration without foreign body, left ankle, subsequent S91.012S Laceration without foreign body, left ankle, S91.019A Laceration without foreign body, unspecified ankle, initial S91.019D Laceration without foreign body, unspecified ankle, subsequent S91.019S Laceration without foreign body, unspecified ankle, 23

24 Name Open wound of toe(s), complicated S91.031A right ankle, initial S91.031D right ankle, subsequent S91.031S right ankle, S91.032A left ankle, initial S91.032D left ankle, subsequent S91.032S left ankle, S91.039A unspecified ankle, initial S91.039D unspecified ankle, subsequent S91.039S unspecified ankle, S91.051A Open bite, right ankle, initial S91.051D Open bite, right ankle, subsequent S91.051S Open bite, right ankle, S91.052A Open bite, left ankle, initial S91.052D Open bite, left ankle, subsequent S91.052S Open bite, left ankle, S91.059A Open bite, unspecified ankle, initial S91.059D Open bite, unspecified ankle, subsequent S91.059S Open bite, unspecified ankle, S91.121A Laceration with foreign body of right great toe without damage to nail, initial S91.121D Laceration with foreign body of right great toe without damage to nail, subsequent S91.121S Laceration with foreign body of right great toe without damage to nail, S91.122A Laceration with foreign body of left great toe without damage to nail, initial S91.122D Laceration with foreign body of left great toe without damage to nail, subsequent S91.122S Laceration with foreign body of left great toe without damage to nail, S91.123A Laceration with foreign body of unspecified great toe without damage to nail, initial 24

25 Name S91.123D Laceration with foreign body of unspecified great toe without damage to nail, subsequent S91.123S Laceration with foreign body of unspecified great toe without damage to nail, S91.124A Laceration with foreign body of right lesser toe(s) without damage to nail, initial S91.124D Laceration with foreign body of right lesser toe(s) without damage to nail, subsequent S91.124S Laceration with foreign body of right lesser toe(s) without damage to nail, S91.125A Laceration with foreign body of left lesser toe(s) without damage to nail, initial S91.125D Laceration with foreign body of left lesser toe(s) without damage to nail, subsequent S91.125S Laceration with foreign body of left lesser toe(s) without damage to nail, S91.126A Laceration with foreign body of unspecified lesser toe(s) without damage to nail, initial S91.126D Laceration with foreign body of unspecified lesser toe(s) without damage to nail, subsequent S91.126S Laceration with foreign body of unspecified lesser toe(s) without damage to nail, S91.129A Laceration with foreign body of unspecified toe(s) without damage to nail, initial S91.129D Laceration with foreign body of unspecified toe(s) without damage to nail, subsequent S91.129S Laceration with foreign body of unspecified toe(s) without damage to nail, S91.141A right great toe without damage to nail, initial S91.141D right great toe without damage to nail, subsequent S91.141S right great toe without damage to nail, 25

26 Name S91.142A left great toe without damage to nail, initial S91.142D left great toe without damage to nail, subsequent S91.142S left great toe without damage to nail, S91.143A unspecified great toe without damage to nail, initial S91.143D unspecified great toe without damage to nail, subsequent S91.143S unspecified great toe without damage to nail, S91.144A right lesser toe(s) without damage to nail, initial S91.144D right lesser toe(s) without damage to nail, subsequent S91.144S right lesser toe(s) without damage to nail, S91.145A left lesser toe(s) without damage to nail, initial S91.145D left lesser toe(s) without damage to nail, subsequent S91.145S left lesser toe(s) without damage to nail, S91.146A unspecified lesser toe(s) without damage to nail, initial S91.146D unspecified lesser toe(s) without damage to nail, subsequent S91.146S unspecified lesser toe(s) without damage to nail, S91.149A unspecified toe(s) without damage to nail, initial S91.149D unspecified toe(s) without damage to nail, subsequent S91.149S unspecified toe(s) without damage to nail, 26

27 Name S91.221A Laceration with foreign body of right great toe with damage to nail, initial S91.221D Laceration with foreign body of right great toe with damage to nail, subsequent S91.221S Laceration with foreign body of right great toe with damage to nail, S91.222A Laceration with foreign body of left great toe with damage to nail, initial S91.222D Laceration with foreign body of left great toe with damage to nail, subsequent S91.222S Laceration with foreign body of left great toe with damage to nail, S91.223A Laceration with foreign body of unspecified great toe with damage to nail, initial S91.223D Laceration with foreign body of unspecified great toe with damage to nail, subsequent S91.223S Laceration with foreign body of unspecified great toe with damage to nail, S91.224A Laceration with foreign body of right lesser toe(s) with damage to nail, initial S91.224D Laceration with foreign body of right lesser toe(s) with damage to nail, subsequent S91.224S Laceration with foreign body of right lesser toe(s) with damage to nail, S91.225A Laceration with foreign body of left lesser toe(s) with damage to nail, initial S91.225D Laceration with foreign body of left lesser toe(s) with damage to nail, subsequent S91.225S Laceration with foreign body of left lesser toe(s) with damage to nail, S91.226A Laceration with foreign body of unspecified lesser toe(s) with damage to nail, initial S91.226D Laceration with foreign body of unspecified lesser toe(s) with damage to nail, subsequent S91.226S Laceration with foreign body of unspecified lesser toe(s) with damage to nail, 27

28 Name S91.229A Laceration with foreign body of unspecified toe(s) with damage to nail, initial S91.229D Laceration with foreign body of unspecified toe(s) with damage to nail, subsequent S91.229S Laceration with foreign body of unspecified toe(s) with damage to nail, S91.241A right great toe with damage to nail, initial S91.241D right great toe with damage to nail, subsequent S91.241S right great toe with damage to nail, S91.242A left great toe with damage to nail, initial S91.242D left great toe with damage to nail, subsequent S91.242S left great toe with damage to nail, S91.243A unspecified great toe with damage to nail, initial S91.243D unspecified great toe with damage to nail, subsequent S91.243S unspecified great toe with damage to nail, S91.244A right lesser toe(s) with damage to nail, initial S91.244D right lesser toe(s) with damage to nail, subsequent S91.244S right lesser toe(s) with damage to nail, S91.245A left lesser toe(s) with damage to nail, initial S91.245D left lesser toe(s) with damage to nail, subsequent S91.245S left lesser toe(s) with damage to nail, 28

29 Name Open wound of toe(s), with tendon involvement S91.246A unspecified lesser toe(s) with damage to nail, initial S91.246D unspecified lesser toe(s) with damage to nail, subsequent S91.246S unspecified lesser toe(s) with damage to nail, S91.249A unspecified toe(s) with damage to nail, initial S91.249D unspecified toe(s) with damage to nail, subsequent S91.249S unspecified toe(s) with damage to nail, S91.109A Unspecified open wound of unspecified toe(s) without damage to nail, initial S91.109D Unspecified open wound of unspecified toe(s) without damage to nail, subsequent S91.109S Unspecified open wound of unspecified toe(s) without damage to nail, S91.209A Unspecified open wound of unspecified toe(s) with damage to nail, initial S91.209D Unspecified open wound of unspecified toe(s) with damage to nail, subsequent S91.209S Unspecified open wound of unspecified toe(s) with damage to nail, S96.929A Laceration of unspecified muscle and tendon at ankle and foot level, unspecified foot, initial S96.929D Laceration of unspecified muscle and tendon at ankle and foot level, unspecified foot, subsequent S96.929S Laceration of unspecified muscle and tendon at ankle and foot level, unspecified foot, 29

30 Name Open wound of toe(s), without mention of complication S91.101A Unspecified open wound of right great toe without damage to nail, initial S91.101D Unspecified open wound of right great toe without damage to nail, subsequent S91.101S Unspecified open wound of right great toe without damage to nail, S91.102A Unspecified open wound of left great toe without damage to nail, initial S91.102D Unspecified open wound of left great toe without damage to nail, subsequent S91.102S Unspecified open wound of left great toe without damage to nail, S91.103A Unspecified open wound of unspecified great toe without damage to nail, initial S91.103D Unspecified open wound of unspecified great toe without damage to nail, subsequent S91.103S Unspecified open wound of unspecified great toe without damage to nail, S91.104A Unspecified open wound of right lesser toe(s) without damage to nail, initial S91.104D Unspecified open wound of right lesser toe(s) without damage to nail, subsequent S91.104S Unspecified open wound of right lesser toe(s) without damage to nail, S91.105A Unspecified open wound of left lesser toe(s) without damage to nail, initial S91.105D Unspecified open wound of left lesser toe(s) without damage to nail, subsequent S91.105S Unspecified open wound of left lesser toe(s) without damage to nail, S91.106A Unspecified open wound of unspecified lesser toe(s) without damage to nail, initial S91.106D Unspecified open wound of unspecified lesser toe(s) without damage to nail, subsequent S91.106S Unspecified open wound of unspecified lesser toe(s) without damage to nail, 30

31 Name S91.109A Unspecified open wound of unspecified toe(s) without damage to nail, initial S91.109D Unspecified open wound of unspecified toe(s) without damage to nail, subsequent S91.109S Unspecified open wound of unspecified toe(s) without damage to nail, S91.111A Laceration without foreign body of right great toe without damage to nail, initial S91.111D Laceration without foreign body of right great toe without damage to nail, subsequent S91.111S Laceration without foreign body of right great toe without damage to nail, S91.112A Laceration without foreign body of left great toe without damage to nail, initial S91.112D Laceration without foreign body of left great toe without damage to nail, subsequent S91.112S Laceration without foreign body of left great toe without damage to nail, S91.113A Laceration without foreign body of unspecified great toe without damage to nail, initial S91.113D Laceration without foreign body of unspecified great toe without damage to nail, subsequent S91.113S Laceration without foreign body of unspecified great toe without damage to nail, S91.114A Laceration without foreign body of right lesser toe(s) without damage to nail, initial S91.114D Laceration without foreign body of right lesser toe(s) without damage to nail, subsequent S91.114S Laceration without foreign body of right lesser toe(s) without damage to nail, S91.115A Laceration without foreign body of left lesser toe(s) without damage to nail, initial S91.115D Laceration without foreign body of left lesser toe(s) without damage to nail, subsequent S91.115S Laceration without foreign body of left lesser toe(s) without damage to nail, 31

32 Name S91.116A Laceration without foreign body of unspecified lesser toe(s) without damage to nail, initial S91.116D Laceration without foreign body of unspecified lesser toe(s) without damage to nail, subsequent S91.116S Laceration without foreign body of unspecified lesser toe(s) without damage to nail, S91.119A Laceration without foreign body of unspecified toe without damage to nail, initial S91.119D Laceration without foreign body of unspecified toe without damage to nail, subsequent S91.119S Laceration without foreign body of unspecified toe without damage to nail, S91.131A Puncture wound without foreign body of right great toe without damage to nail, initial S91.131D Puncture wound without foreign body of right great toe without damage to nail, subsequent S91.131S Puncture wound without foreign body of right great toe without damage to nail, S91.132A Puncture wound without foreign body of left great toe without damage to nail, initial S91.132D Puncture wound without foreign body of left great toe without damage to nail, subsequent S91.132S Puncture wound without foreign body of left great toe without damage to nail, S91.133A Puncture wound without foreign body of unspecified great toe without damage to nail, initial S91.133D Puncture wound without foreign body of unspecified great toe without damage to nail, subsequent S91.133S Puncture wound without foreign body of unspecified great toe without damage to nail, S91.134A Puncture wound without foreign body of right lesser toe(s) without damage to nail, initial S91.134D Puncture wound without foreign body of right lesser toe(s) without damage to nail, subsequent S91.134S Puncture wound without foreign body of right lesser toe(s) without damage to nail, 32

33 Name S91.135A Puncture wound without foreign body of left lesser toe(s) without damage to nail, initial S91.135D Puncture wound without foreign body of left lesser toe(s) without damage to nail, subsequent S91.135S Puncture wound without foreign body of left lesser toe(s) without damage to nail, S91.136A Puncture wound without foreign body of unspecified lesser toe(s) without damage to nail, initial S91.136D Puncture wound without foreign body of unspecified lesser toe(s) without damage to nail, subsequent S91.136S Puncture wound without foreign body of unspecified lesser toe(s) without damage to nail, S91.139A Puncture wound without foreign body of unspecified toe(s) without damage to nail, initial S91.139D Puncture wound without foreign body of unspecified toe(s) without damage to nail, subsequent S91.139S Puncture wound without foreign body of unspecified toe(s) without damage to nail, S91.151A Open bite of right great toe without damage to nail, initial S91.151D Open bite of right great toe without damage to nail, subsequent S91.151S Open bite of right great toe without damage to nail, S91.152A Open bite of left great toe without damage to nail, initial S91.152D Open bite of left great toe without damage to nail, subsequent S91.152S Open bite of left great toe without damage to nail, S91.153A Open bite of unspecified great toe without damage to nail, initial S91.153D Open bite of unspecified great toe without damage to nail, subsequent S91.153S Open bite of unspecified great toe without damage to nail, S91.154A Open bite of right lesser toe(s) without damage to nail, initial S91.154D Open bite of right lesser toe(s) without damage to nail, subsequent S91.154S Open bite of right lesser toe(s) without damage to nail, 33

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