ICD 10 CM S91.04 | Description & Clinical Information

ICD 10 S91.04 describes a specific type of injury to the ankle, which involves the piercing of the skin by a sharp object such as a needle, glass, nail, or wood splinter, resulting in the retention of a foreign body within the wound.

Official Description Of S91.04

The ICD 10 CM book defines ICD 10 code S91.04 as:

When To Use S91.04

The diagnosis describes by ICD 10 CM code S91.04 is a puncture wound in the ankle region caused by a foreign object penetrating the skin. This type of injury can cause severe pain, tenderness, and swelling in the affected area, leading to restricted motion and difficulty walking.
Medical providers use a variety of methods to diagnose puncture wounds with foreign objects. The first step is to assess the patient’s medical history, including any underlying medical conditions or risk factors that may affect the injury’s severity. The provider will then perform a physical examination of the wound, checking for signs of local tissue damage, nerve or blood vessel damage, and infection risk. They may also use imaging techniques such as X-rays, computed tomography (CT), or magnetic resonance imaging (MRI) to evaluate the wound’s depth and severity and determine the foreign object’s location within the tissue.
Treatment options for puncture wounds with foreign objects depend on the wound’s location, severity, and potential for complications. The first step is to control any bleeding or discharge from the wound. Then, the wound should be cleaned thoroughly, removing any dirt or debris and flushing out the foreign object if possible. Applying appropriate topical medication and dressing the wound appropriately is essential to promoting healing and preventing infection. Pain management is also a vital aspect of treatment, and providers may prescribe analgesics or nonsteroidal anti-inflammatory drugs (NSAIDs) to help manage discomfort. Antibiotics may also be necessary to prevent or treat infection, depending on the patient’s medical history and the wound’s severity. Finally, a tetanus prophylaxis may also be necessary to prevent tetanus infection.
Prevention of puncture wounds with foreign objects is essential to avoid complications that can arise from these types of injuries. Following preventive measures, such as wearing appropriate footwear in hazardous environments, using protective gear when working with sharp objects or machinery, and practicing good wound care can help reduce the risk of developing a puncture wound with a foreign object. In summary, medical coders should accurately code puncture wounds with foreign objects as ICD 10 CM code S91.04 and understand the diagnostic and treatment process for these types of injuries.