ICD-10 Code for Skin Tear on the Forearm
For a traumatic skin tear on the forearm, use ICD-10-CM code S51.819A (Laceration without foreign body of unspecified forearm, initial encounter). 1
Code Structure and Specificity
The ICD-10-CM system requires specific anatomical documentation for traumatic skin tears. 1 The forearm is defined as the area between the elbow and wrist, distinct from the lower leg (knee to ankle). 1 The code structure follows this pattern:
- S51: Injury to the forearm
- 8: Laceration (skin tear falls under this category)
- 1: Without foreign body
- 9: Unspecified forearm (use 1 for right, 2 for left if laterality is documented)
- A: Initial encounter
Seventh Character Modifiers
The seventh character must be adjusted based on the encounter type: 1
- "A": Initial encounter (first treatment)
- "D": Subsequent encounter (during healing phase for follow-up visits)
- "S": Sequela (for long-term complications after healing)
Additional Coding Considerations
If the skin tear becomes infected or develops complications, add code L08.9 (Local infection of skin and subcutaneous tissue, unspecified) as a secondary diagnosis. 1 This is critical because skin tears, particularly in older adults with fragile skin, carry significant infection risk. 2, 3
Common Pitfalls to Avoid
- Do not use chronic wound codes: Skin tears are acute traumatic injuries, not chronic ulcers or pressure injuries, despite their prevalence in elderly patients with fragile skin. 1, 4, 3
- Document laterality when known: Using S51.811A (right) or S51.812A (left) instead of S51.819A (unspecified) improves coding accuracy. 5
- Include external cause codes: While not always required, adding an external cause code (W codes) improves injury surveillance data, though completeness varies by institution. 6
Clinical Context
Skin tears are frequently misdiagnosed and under-reported traumatic wounds that cause significant pain and reduced mobility, particularly in older adults. 4, 3 The International Skin Tear Advisory Panel (ISTAP) Classification System provides standardized assessment (Types 1-3 based on skin flap viability), but for ICD-10 coding purposes, all skin tears are coded as lacerations regardless of ISTAP type. 4, 3