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  6. 2024 ICD-10-CM Code S41.109

2024 ICD-10-CM Diagnosis Code S41.109

Unspecified open wound of unspecified upper arm

ICD-10-CM Code:
S41.109
ICD-10 Code for:
Unspecified open wound of unspecified upper arm
Is Billable?
Not Valid for Submission
Code Navigator:

Code Classification

  • Injury, poisoning and certain other consequences of external causes
    (S00–T88)
    • Injuries to the shoulder and upper arm
      (S40-S49)
      • Open wound of shoulder and upper arm
        (S41)

S41.109 is a non-specific and non-billable diagnosis code code, consider using a code with a higher level of specificity for a diagnosis of unspecified open wound of unspecified upper arm. The code is not specific and is NOT valid for the year 2024 for the submission of HIPAA-covered transactions. Category or Header define the heading of a category of codes that may be further subdivided by the use of 4th, 5th, 6th or 7th characters.

Unspecified diagnosis codes like S41.109 are acceptable when clinical information is unknown or not available about a particular condition. Although a more specific code is preferable, unspecified codes should be used when such codes most accurately reflect what is known about a patient's condition. Specific diagnosis codes should not be used if not supported by the patient's medical record.

Specific Coding Applicable to Unspecified open wound of unspecified upper arm

Non-specific codes like S41.109 require more digits to indicate the appropriate level of specificity. Consider using any of the following ICD-10-CM codes with a higher level of specificity when coding for unspecified open wound of unspecified upper arm:

  • Use S41.109A for initial encounter - BILLABLE CODE

  • Use S41.109D for subsequent encounter - BILLABLE CODE

  • Use S41.109S for sequela - BILLABLE CODE

Approximate Synonyms

The following clinical terms are approximate synonyms or lay terms that might be used to identify the correct diagnosis code:

  • Crushing injury of axillary region
  • Crushing injury of upper arm
  • Elbow fracture - open
  • Fracture of lesser tuberosity of humerus
  • Fracture of medial condyle of humerus
  • Fracture of the lateral humeral epicondyle
  • Fracture of the medial humeral epicondyle
  • Glass in axilla
  • Glass in shoulder
  • Glass in upper arm
  • Injury of axillary artery
  • Injury of axillary vein
  • Injury of brachial artery
  • Injury of brachial plexus trunk
  • Injury of musculocutaneous nerve
  • Multiple fractures of humerus
  • Multiple open dislocations of arm
  • Multiple open fractures of distal humerus
  • Multiple open wounds of shoulder
  • Multiple open wounds of shoulder and upper arm
  • Multiple open wounds of upper arm
  • Multiple open wounds of upper arm
  • Multiple open wounds of upper arm
  • Multiple open wounds of upper arm with complication
  • Multiple open wounds of upper limb with complication
  • Multiple open wounds with complication
  • Musculocutaneous nerve lesion
  • Open crush injury, axilla
  • Open crush injury, shoulder area
  • Open crush injury, upper arm
  • Open fracture distal humerus, bicondylar
  • Open fracture distal humerus, lateral epicondyle
  • Open fracture of condyle of humerus
  • Open fracture of humerus, upper epiphysis
  • Open fracture of humerus, upper epiphysis
  • Open fracture of lateral condyle of humerus
  • Open fracture of lesser tuberosity of humerus
  • Open fracture of lower epiphysis of humerus
  • Open fracture of lower epiphysis of humerus
  • Open fracture of lower epiphysis of humerus
  • Open fracture of medial condyle of humerus
  • Open fracture of medial epicondyle of humerus
  • Open fracture of upper end of humerus
  • Open fracture of upper end of humerus
  • Open injury, axillary artery
  • Open injury, axillary vein
  • Open injury, brachial artery
  • Open injury, brachial plexus, lower roots
  • Open injury, musculocutaneous nerve
  • Open multiple fractures of clavicle and/or scapula and/or humerus
  • Open supracondylar fracture of humerus
  • Open transcondylar fracture of distal humerus
  • Open wound of axillary region
  • Open wound of axillary region with complication
  • Open wound of shoulder region with complication
  • Open wound of upper arm
  • Open wound of upper arm with complication
  • Open wound of upper arm with complication
  • Pellet wound of axilla
  • Pellet wound of shoulder
  • Supracondylar fracture of humerus
  • Transcondylar fracture of distal humerus
  • Wound of axillary region

Coding Guidelines

The appropriate 7th character is to be added to each code from block Open wound of shoulder and upper arm (S41). Use the following options for the aplicable episode of care:

  • A - initial encounter
  • D - subsequent encounter
  • S - sequela

Patient Education


Arm Injuries and Disorders

Of the 206 bones in your body, three of them are in your arm: the humerus, radius, and ulna. Your arms are also made up of muscles, joints, tendons, and other connective tissue. Injuries to any of these parts of the arm can occur during sports, a fall, or an accident.

Types of arm injuries include :

  • Tendinitis and bursitis
  • Sprains
  • Dislocations
  • Fractures (broken bones)
  • Nerve problems
  • Osteoarthritis

You may also have problems or injure specific parts of your arm, such as your hand, wrist, elbow, or shoulder.


[Learn More in MedlinePlus]

Wounds and Injuries

An injury is damage to your body. It is a general term that refers to harm caused by accidents, falls, hits, weapons, and more. In the U.S., millions of people injure themselves every year. These injuries range from minor to life-threatening. Injuries can happen at work or play, indoors or outdoors, driving a car, or walking across the street.

Wounds are injuries that break the skin or other body tissues. They include cuts, scrapes, scratches, and punctured skin. They often happen because of an accident, but surgery, sutures, and stitches also cause wounds. Minor wounds usually aren't serious, but it is important to clean them. Serious and infected wounds may require first aid followed by a visit to your doctor. You should also seek attention if the wound is deep, you cannot close it yourself, you cannot stop the bleeding or get the dirt out, or it does not heal.

Other common types of injuries include:

  • Animal bites
  • Bruises
  • Burns
  • Dislocations
  • Electrical injuries
  • Fractures (broken bones)
  • Sprains and strains

[Learn More in MedlinePlus]

Code History

  • FY 2024 - No Change, effective from 10/1/2023 through 9/30/2024
  • FY 2023 - No Change, effective from 10/1/2022 through 9/30/2023
  • FY 2022 - No Change, effective from 10/1/2021 through 9/30/2022
  • FY 2021 - No Change, effective from 10/1/2020 through 9/30/2021
  • FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020
  • FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
  • FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
  • FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
  • FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016. This was the first year ICD-10-CM was implemented into the HIPAA code set.