ICD-10-CM Coding for Infected Laceration
For a laceration with infection, you must use two separate codes: one from the S-series for the laceration itself (specifying anatomic location, laterality, and episode of care) and an additional code from L08.9 (local infection of skin and subcutaneous tissue, unspecified) or a more specific infection code to capture the infectious complication.
Primary Laceration Code Structure
The laceration code follows this format based on anatomic location:
- S01.- for head lacerations
- S11.- for neck lacerations
- S21.- for thorax lacerations
- S31.- for abdomen/pelvis lacerations
- S41.- for shoulder/upper arm lacerations
- S51.- for elbow/forearm lacerations
- S61.- for wrist/hand lacerations
- S71.- for hip/thigh lacerations
- S81.- for knee/lower leg lacerations
- S91.- for ankle/foot lacerations
Each code requires:
- Specific anatomic detail (e.g., S61.411 for laceration without foreign body of right hand)
- Laterality (right, left, or unspecified)
- 7th character extension indicating episode of care:
- A = initial encounter
- D = subsequent encounter
- S = sequela
Secondary Infection Code
Add L08.9 (local infection of skin and subcutaneous tissue, unspecified) as a secondary diagnosis to document the infectious complication. If the specific organism or infection type is known, use a more specific code from the L08 series.
Clinical Context from Evidence
Understanding infection risk factors helps ensure accurate documentation:
- Lower extremity lacerations carry significantly higher infection rates (8.5% vs. 2% overall) 1, 2
- Lacerations >5 cm have nearly 3-fold increased infection risk 3, 2
- Diabetes increases infection risk 6.7-fold 3
- Contaminated wounds and presence of foreign bodies double infection risk 3, 2
Coding Example
For an infected laceration of the right hand on initial presentation:
- S61.411A (Laceration without foreign body of right hand, initial encounter)
- L08.9 (Local infection of skin and subcutaneous tissue, unspecified)
The transition to ICD-10-CM provides substantially more anatomic specificity than ICD-9-CM, allowing more precise injury surveillance and documentation 4.