Find information on right thumb laceration diagnosis, treatment, and documentation. This resource covers clinical findings, ICD-10 codes (S61), CPT codes for repair, wound care, and aftercare. Learn about thumb laceration depth classification, repair techniques, and potential complications like infection or tendon injury. Resources for healthcare professionals, including physicians, nurses, and medical coders, focusing on accurate and efficient clinical documentation.
Also known as
Open wound of thumb
Covers open wounds like lacerations specifically of the thumb.
Injuries to hand and wrist
Includes various injuries to the hand and wrist region.
Injuries to the extremities
Encompasses a broader range of injuries affecting limbs.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the laceration open?
When to use each related code
| Description |
|---|
| Right Thumb Laceration |
| Right Thumb Avulsion |
| Right Thumb Wound |
Coding lacks laterality (right vs. left), impacting reimbursement and data accuracy. CDI should query for clarity.
Missing documentation of laceration depth (e.g., superficial, full-thickness) affects code selection and payment. CDI intervention needed.
Unspecified repair type (e.g., sutures, staples, adhesive) can lead to undercoding and lost revenue. CDI should clarify.
Patient presents with a right thumb laceration. The mechanism of injury was reported as accidental contact with a sharp object. On examination, a laceration is noted on the right thumb, involving the (specify location: volar, dorsal, radial, ulnar aspect; distal, middle, proximal phalanx). The laceration measures (length) x (width) x (depth) centimeters. Wound edges are (sharp, jagged, irregular). Bleeding is (minimal, moderate, profuse; controlled, ongoing). Neurovascular status of the right thumb is intact, with capillary refill less than 2 seconds, palpable radial pulse, and normal sensation to light touch. Surrounding skin is (intact, erythematous, ecchymotic). Signs of infection, such as purulent drainage, warmth, or lymphangitis, are absent. Tetanus status is (up-to-date, unknown, requires booster). The wound was cleansed with normal saline and irrigated. Treatment included (sutures, Steri-Strips, surgical glue) to approximate wound edges. Patient tolerated the procedure well. Wound care instructions provided, including signs of infection to monitor and follow-up care. Patient advised to return for suture removal in (number) days. Diagnosis: Right thumb laceration. ICD-10 code: (insert appropriate code, e.g., S61.111A for laceration of right thumb, unspecified part, initial encounter). CPT codes: (insert appropriate codes for wound repair and other procedures performed, e.g., 12001 for simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and extremities up to 2.5 cm).