ICD-10 Coding for Left Great Toe Wound(S91.102A, S91.122A)
Complete ICD-10-CM coding and documentation guide for Left Great Toe Wound. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Left Great Toe Wound
S91.1-S91.2Primary Range
Open wound of toe(s) without and with nail damage
This range covers traumatic wounds specific to the toes, including the left great toe, with or without nail involvement.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S91.102A | Laceration without foreign body, left great toe, initial encounter | Use for initial encounters of open wounds on the left great toe without nail damage. |
|
| S91.122A | Laceration with foreign body, left great toe, initial encounter | Use for initial encounters of open wounds on the left great toe with nail damage. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for left great toe wound
Essential facts and insights about Left Great Toe Wound
Primary ICD-10-CM Codes for left great toe wound
Decision Criteria
clinical Criteria
- Presence of an open wound on the left great toe without nail damage
coding Criteria
- Initial encounter for the wound
Applicable To
- Open wound of left great toe without nail damage
Excludes
- Open wound with nail damage (S91.122A)
Clinical Validation Requirements
- Documentation of laceration on left great toe without nail involvement
- Mechanism of injury, such as stepping on a nail
Code-Specific Risks
- Incorrect laterality documentation
- Confusion with chronic ulcers
Coding Notes
- Ensure laterality is specified and differentiate between traumatic wounds and chronic ulcers.
S91.122A - Laceration with foreign body, left great toe, initial encounter
Use for initial encounters of open wounds on the left great toe with nail damage.
Applicable To
- Open wound of left great toe with nail damage
Excludes
- Open wound without nail damage (S91.102A)
Clinical Validation Requirements
- Documentation of laceration on left great toe with nail involvement
- Imaging showing nail bed disruption
Coding Notes
Ensure laterality is specified and differentiate between traumatic wounds and chronic ulcers.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
MRSA isolation from wound culture
B97.2Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Non-pressure chronic ulcer of skin of lower limb
L97.4-Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Left Great Toe Wound to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S91.102A.
Impact
Clinical: Misrepresentation of the patient's condition., Regulatory: Potential for audit issues., Financial: Incorrect DRG assignment affecting reimbursement.
Mitigation Strategy
Verify the etiology of the wound., Use S91 codes for traumatic wounds.
Impact
Reimbursement: Claims may be denied or delayed., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Inaccurate patient records.
Mitigation Strategy
Always specify 'left' or 'right' in documentation.
Impact
Failure to specify laterality can lead to claim denials.
Mitigation Strategy
Implement mandatory fields in EHR for laterality.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Left Great Toe Wound, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Left Great Toe Wound
Use these documentation templates to ensure complete and accurate documentation for Left Great Toe Wound. These templates include all required elements for proper coding and billing.
Initial encounter for left great toe wound
Specialty: PodiatryRequired Elements
- Location
- Size
- Wound bed appearance
- Exudate
- Periwound skin
- Treatment
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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