Find information on stepped on nail injuries including diagnosis codes, clinical documentation tips, and healthcare guidance. Learn about puncture wound treatment, foreign body removal, tetanus risk assessment, and appropriate medical coding for stepped on nail incidents. Explore resources for healthcare professionals regarding infection prevention, pain management, and aftercare instructions for patients who have stepped on a nail.
Also known as
Injuries to the foot and ankle
Covers injuries like stepping on a nail.
Exposure to inanimate mechanical forces
Includes injuries from contact with sharp objects.
Intentional self-harm
Relevant if nail stepping was intentional self-harm.
Place of occurrence of the external cause
Provides codes to specify the location of the injury.
Follow this step-by-step guide to choose the correct ICD-10 code.
Nail penetrated skin?
Yes
Infection present?
No
Contusion/hematoma present?
When to use each related code
| Description |
|---|
| Stepped on nail |
| Puncture wound, foot |
| Foot foreign body |
Using unspecified codes like S00.90xA when more specific documentation supports codes like S01.11xA for nail bed injuries. Impacts reimbursement and data accuracy.
Failing to code for retained foreign body (e.g., rust) if present, like S01.81xA. Leads to incomplete clinical picture and missed CC/MCC capture.
Incorrectly coding cellulitis/infection related to the nail injury without clear documentation. May trigger audits for unjustified upcoding.
Patient presents with a complaint of stepped on nail injury. Onset occurred [Date] at [Time] while [Activity causing injury]. Patient reports [sharp, dull, throbbing] pain in the [affected foot, toe] rated [pain scale 1-10]. Visual inspection reveals [puncture wound, laceration, bleeding, bruising, swelling, erythema, foreign body presence if applicable] at the [plantar surface, dorsal surface] of the [specify toe or foot area]. Neurovascular assessment of the affected extremity shows [intact sensation, diminished sensation, absent sensation, palpable pulses, diminished pulses, absent pulses, capillary refill time]. Tetanus status was reviewed and is [up-to-date, not up-to-date, unknown]. Wound was irrigated with normal saline. [Foreign body removal if applicable, describe method]. Wound was dressed with [dressing type]. Patient education provided regarding wound care, signs of infection, and pain management. Diagnosis: Puncture wound foot, stepped on nail. Plan: [Analgesics prescribed, antibiotics prescribed if indicated, tetanus immunization administered if indicated, follow-up instructions]. Return to clinic if signs of infection develop, including increased pain, swelling, redness, purulent drainage, or fever.