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S61.011A
ICD-10-CM
Right Thumb Laceration

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

Laceration of Right Thumb
Right Thumb Cut

Related ICD-10 Code Ranges

Complete code families applicable to AAPC S61.011A Coding
S61

Open wound of thumb

Covers open wounds like lacerations specifically of the thumb.

S60-S69

Injuries to hand and wrist

Includes various injuries to the hand and wrist region.

S00-S99

Injuries to the extremities

Encompasses a broader range of injuries affecting limbs.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the laceration open?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Right Thumb Laceration
Right Thumb Avulsion
Right Thumb Wound

Documentation Best Practices

Documentation Checklist
  • Document laceration location, depth, length
  • Describe wound characteristics (e.g., clean, jagged)
  • Record any tendon/nerve involvement
  • Detail any repair technique used
  • Document neurovascular status pre and post-repair

Coding and Audit Risks

Common Risks
  • Unspecified Laterality

    Coding lacks laterality (right vs. left), impacting reimbursement and data accuracy. CDI should query for clarity.

  • Depth/Extent Unclear

    Missing documentation of laceration depth (e.g., superficial, full-thickness) affects code selection and payment. CDI intervention needed.

  • Repair Type Missing

    Unspecified repair type (e.g., sutures, staples, adhesive) can lead to undercoding and lost revenue. CDI should clarify.

Mitigation Tips

Best Practices
  • Document precise location, depth, & cause of laceration for accurate ICD-10 coding (S61).
  • Ensure clear wound size documentation in cm for proper CPT coding (e.g., 12001-12021).
  • Photo-document wound for improved CDI & medico-legal compliance.
  • Evaluate & document digital nerve/tendon involvement for proper coding & treatment.
  • Timely post-laceration care instructions promote healing & prevent complications, improving outcomes.

Clinical Decision Support

Checklist
  • Confirm laterality: Is it truly the RIGHT thumb?
  • Document wound depth: Superficial, partial, or full thickness?
  • Tendon involvement: Check ROM, FDS, FDP function.
  • Neurovascular status: Assess sensation and capillary refill.
  • Consider imaging if complex: Xray for fracture?

Reimbursement and Quality Metrics

Impact Summary
  • Right Thumb Laceration reimbursement: CPT codes impact payment accuracy. Proper coding maximizes revenue.
  • Coding quality metrics: Accurate laceration repair coding affects hospital quality reporting and value-based care.
  • Laceration repair documentation: Detailed notes improve coding accuracy, impacting CMI and reimbursement.
  • Thumb laceration severity: Complexity influences coding (simple, intermediate, complex) impacting reimbursement.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code thumb laceration depth, repair type
  • Document right thumb location, laterality
  • Check S61 ICD-10, CPT repair codes
  • Consider fingertip, nail involvement
  • Add cause, intent if traumatic

Documentation Templates

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).
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