ICD-10 Codes for Traumatic Skin Injuries
The appropriate ICD-10 codes for bullous wound due to trauma, wound due to contusion, and skin tear are S30.821A (blister/bullous wound), S40.0XXA (contusion), and S91.311A (skin tear), with specific anatomical site codes varying based on the location of the injury.
Bullous Wound Due to Trauma
Bullous wounds (blisters) caused by trauma are coded using the following structure:
- Base code: S__.82_A (blister/bullous wound)
- First blank: Anatomical region (e.g., S30 for abdomen, S40 for shoulder/upper arm)
- Last blank: Specific site within the region
- A: Initial encounter
Common examples:
- S30.821A: Blister of abdominal wall, initial encounter
- S40.821A: Blister of right shoulder, initial encounter
- S50.821A: Blister of right elbow, initial encounter
- S60.821A: Blister of right hand, initial encounter
Wound Due to Contusion
Contusion wounds are coded using the following structure:
- Base code: S__.0XXA (contusion)
- Blank: Anatomical region
- A: Initial encounter
Common examples:
- S40.0XXA: Contusion of shoulder and upper arm, initial encounter
- S50.0XXA: Contusion of elbow, initial encounter
- S60.0XXA: Contusion of finger without damage to nail, initial encounter
- S70.0XXA: Contusion of hip, initial encounter
Skin Tear
Skin tears are coded using the following structure:
- Base code: S__.31_A (skin tear)
- First blank: Anatomical region
- Last blank: Specific site and laterality (1=right, 2=left)
- A: Initial encounter
Common examples:
- S91.311A: Skin tear, right ankle, initial encounter
- S91.312A: Skin tear, left ankle, initial encounter
- S51.311A: Skin tear, right elbow, initial encounter
- S51.312A: Skin tear, left elbow, initial encounter
Important Coding Considerations
Seventh character extension is required for all injury codes:
- A: Initial encounter
- D: Subsequent encounter
- S: Sequela (complication or condition resulting from the injury)
External cause codes (V00-Y99) should be added to identify how the injury occurred, the place of occurrence, and the activity of the patient at the time of injury 1.
Laterality must be specified when applicable (right, left, or bilateral).
Multiple injuries should each be coded separately unless a combination code exists.
Wound care documentation should include:
- Size and depth of the wound
- Presence of infection
- Treatment provided
- Follow-up recommendations 2
Wound Management Considerations
When treating these injuries, consider:
- For bullous wounds: Remove the blister roof when there are clinical signs of infection or when the blister is already ruptured 2
- For contusions: Apply cold compresses initially to reduce swelling
- For skin tears: Gently cleanse with antimicrobial solution and apply non-adherent dressing 2
If signs of infection develop, oral antibiotics may be necessary, such as dicloxacillin, cephalexin, clindamycin, or amoxicillin/clavulanate 2.
Remember to verify tetanus immunization status for all traumatic wounds 3.