Find information on hand laceration diagnosis, treatment, and documentation. This resource covers clinical evaluation, wound care, repair techniques, and appropriate medical coding (ICD-10, CPT) for lacerations of the hand. Learn about hand anatomy, differential diagnoses, complications like infections and nerve damage, and best practices for healthcare professionals. Explore resources on proper medical charting, coding guidelines, and billing for hand laceration repair.
Also known as
Injuries to the wrist and hand
Covers various injuries affecting the wrist and hand, including lacerations.
Injuries to the thorax
While less common, hand lacerations may occur with thoracic injuries.
Injuries to the head
Hand lacerations can sometimes accompany head injuries due to falls or trauma.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the hand laceration open?
Yes
Which part of hand?
No
Not a laceration. Review documentation and consider alternative diagnoses.
When to use each related code
| Description |
|---|
| Hand laceration |
| Hand avulsion |
| Open hand wound |
Lack of documentation specifying laceration depth, complexity (e.g., tendon involvement), and exact location impacts accurate code assignment (e.g., S61, S62).
Missing documentation of repair type (simple, intermediate, complex) and length affects proper coding and reimbursement for the procedure.
Unspecified laterality (right, left) for hand lacerations can lead to coding errors and claim denials. Clear documentation is crucial.
Patient presents with a hand laceration. Detailed history including mechanism of injury, time of incident, and hand dominance was obtained. The patient reports (Insert subjective complaint e.g., sharp pain, bleeding, numbness, tingling, limited range of motion). Examination reveals a laceration located on the (specify location: volar/dorsal aspect of the hand, specific digit, thenar/hypothenar eminence, interdigital space) measuring (length x width x depth in centimeters). Wound edges are (describe: clean, jagged, irregular, macerated) and the surrounding tissue exhibits (describe: erythema, edema, ecchymosis, signs of infection, foreign body). Neurovascular assessment of the affected digit(s) reveals (describe: intact sensation, diminished sensation, paresthesia, capillary refill time, palpable pulses). Tetanus status was reviewed. Diagnosis of hand laceration confirmed. Treatment included (describe: irrigation with normal saline, debridement, wound closure with sutures/staples/adhesive strips, application of antibiotic ointment, dressing, splinting). Patient tolerated the procedure well. Wound care instructions provided, including signs of infection to monitor for. Follow-up appointment scheduled for (date) for suture/staple removal and wound check. Differential diagnoses considered included avulsion injury, puncture wound, and tendon injury. ICD-10 code S21 (specify further as needed based on location and depth) and CPT code (specify based on complexity of repair and length of laceration) will be used for billing and coding. Keywords: hand laceration repair, hand injury, wound care, laceration treatment, suture, staples, adhesive closure, digital nerve injury, tendon laceration, hand infection, emergency medicine, hand surgery, wound debridement, medical coding, CPT codes, ICD-10 codes, medical billing, electronic health records.