Skin Tear ICD-10-CM Codes

What ICD-10 codes are used for skin tears?

Skin tears are common injuries characterized by the separation of the epidermis and dermis layers of the skin, often caused by friction or trauma. The proper coding of skin tears is crucial for accurate documentation, billing, and healthcare management. Here are several commonly used Skin Tears ICD Codes, along with their clinical descriptions:

• L08.9: Local infection of skin and subcutaneous tissue, unspecified: This code is used when a skin tear leads to a local infection of the skin and underlying subcutaneous tissue without specifying the exact cause or location of the infection.
• S01.119A: Laceration without foreign body of unspecified eyelid and periocular area, initial encounter: This code represents a skin tear in the eyelid or periocular area without complications. It is typically used when a superficial tear in these regions, such as from accidental trauma or rubbing.
• S01.119D: Laceration without foreign body of unspecified eyelid and periocular area, subsequent encounter: This code indicates a subsequent encounter for a previously documented skin tear in the eyelid or periocular area. It is used for ongoing care and management of the wound.
• S01.129A: Laceration with foreign body of unspecified eyelid and periocular area, initial encounter: This code covers skin tears in other head parts without complications, not including the eyelid or periocular area. It may include tears on the scalp, forehead, or other regions.
• S01.129D: Laceration with foreign body of unspecified eyelid and periocular area, subsequent encounter: Similar to the previous code, this one denotes subsequent encounters for ongoing care and management of skin tears in other areas of the head.
• S41.119A: Laceration without foreign body of unspecified upper arm, initial encounter: This code represents a skin tear on the forearm without complications. It is typically used when a superficial tear is in this area, often caused by accidents or falls.
• S41.119D: Laceration without foreign body of unspecified upper arm, subsequent encounter: This code indicates a subsequent encounter for a previously documented skin tear on the forearm. It is used for ongoing care and management of the wound.
• S41.119S: Laceration without foreign body of unspecified upper arm, sequela: This code is used when lingering sequelae or complications result from a previous skin tear on the forearm.
• S91.001A: Unspecified open wound, right ankle, initial encounter: This code represents an initial encounter for an open wound on the right ankle, such as a skin tear.
• S91.001D: Unspecified open wound, right ankle, subsequent encounter: Similar to the previous code, this one denotes subsequent encounters for ongoing care and management of a previously documented skin tear on the right ankle.

Which skin tear ICD codes are billable?

Here's a breakdown of the commonly used skin tear ICD-10 codes and whether they are billable or not, along with a brief explanation for each code:

• L08.9: Local infection of skin and subcutaneous tissue, unspecified: Yes, it is billable.
• S01.119A: Laceration without foreign body of unspecified eyelid and periocular area, initial encounter: Yes, billable.
• S01.119D: Laceration without foreign body of unspecified eyelid and periocular area, subsequent encounter: Yes, billable.
• S01.129A: Laceration with foreign body of unspecified eyelid and periocular area, initial encounter: Yes, billable.
• S01.129D: Laceration with foreign body of unspecified eyelid and periocular area, subsequent encounter: Yes, billable.
• S41.119A: Laceration without foreign body of unspecified upper arm, initial encounter: Yes, billable.
• S41.119D: Laceration without foreign body of unspecified upper arm, subsequent encounter: Yes, billable.
• S41.119S: Laceration without foreign body of unspecified upper arm, sequela: Yes, billable.
• S91.001A: Unspecified open wound, right ankle, initial encounter: Yes, billable.
• S91.001D: Unspecified open wound, right ankle, subsequent encounter: Yes, billable.

Clinical information

• Skin tears are acute wounds caused by trauma, friction, or shearing forces that separate the skin layers. These wounds commonly affect the upper limb, including the left forearm, right forearm, left hand, right hand, elbow, and wrist, but they can also occur on the lower leg and right lower leg.
• Older adults, who are more prone to skin tears due to thinner skin and reduced elasticity, are most commonly affected. In younger individuals, skin tears may result from open bites, falls, or other traumatic injuries.
• The severity of skin tears can vary and is classified into three categories based on the condition of the skin flap. In Category 1, there is no skin flap loss, and the wound edges can be approximated easily. Category 2 involves partial flap loss, where the skin flap is partially detached but can still be repositioned. Category 3 indicates complete skin flap loss, leaving the wound open and vulnerable to infection or delayed healing.
• Clinically, skin tears present with irregular wound edges and surrounding tissue that may show erythema, swelling, or bruising. In cases of partial flap loss, the skin flap may be fragile and difficult to reposition, increasing the risk of delayed healing.
• Assessment includes evaluating the location of the wound, whether it is on the left forearm, right forearm, elbow, wrist, lower leg, or right lower leg, and determining the extent of tissue damage and the viability of the skin flap.
• Wound care for skin tears focuses on minimizing trauma and promoting healing. To prevent infection, the wound should be gently cleansed with saline or an appropriate solution. If the skin flap is viable, it should be repositioned carefully to cover the wound.
• Non-adherent, moisture-retentive dressings are recommended to protect the surrounding tissue and maintain an optimal healing environment. Regular monitoring for signs of infection, particularly in high-risk areas such as the left hand, right hand, and lower leg, is essential to prevent complications.
• Preventive strategies include maintaining skin hydration, applying protective barriers to vulnerable areas, and taking measures to reduce the risk of trauma. Timely intervention and proper wound management can promote healing and reduce the likelihood of delayed healing or infection.

Synonyms include:

• Lacerations
• Rips
• Cuts
• Incisions
• Wounds
• Abrasions
• Gashes
• Splits
• Torn skin
• Flayed skin