2022 ICD-10-CM Code S41.039

Puncture wound without foreign body of unspecified shoulder

Version 2021

Not Valid for Submission

ICD-10:S41.039
Short Description:Puncture wound without foreign body of unspecified shoulder
Long Description:Puncture wound without foreign body of unspecified shoulder

Code Classification

  • Injury, poisoning and certain other consequences of external causes (S00–T98)
    • Injuries to the shoulder and upper arm (S40-S49)
      • Open wound of shoulder and upper arm (S41)

S41.039 is a non-specific and non-billable diagnosis code code, consider using a code with a higher level of specificity for a diagnosis of puncture wound without foreign body of unspecified shoulder. The code is not specific and is NOT valid for the year 2022 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.

The ICD-10-CM code S41.039 might also be used to specify conditions or terms like nail wound of axilla, nail wound of shoulder, needle stick injury of shoulder, pellet wound of shoulder, puncture wound of shoulder , puncture wound of shoulder, etc.

Unspecified diagnosis codes like S41.039 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.

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:

Specific Coding for Puncture wound without foreign body of unspecified shoulder

Non-specific codes like S41.039 require more digits to indicate the appropriate level of specificity. Consider using any of the following ICD-10 codes with a higher level of specificity when coding for puncture wound without foreign body of unspecified shoulder:

  • BILLABLE CODE - Use S41.039A for initial encounter
  • BILLABLE CODE - Use S41.039D for subsequent encounter
  • BILLABLE CODE - Use S41.039S for sequela

Index to Diseases and Injuries

The Index to Diseases and Injuries is an alphabetical listing of medical terms, with each term mapped to one or more ICD-10 code(s). The following references for the code S41.039 are found in the index:

Approximate Synonyms

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

Information for Patients


Shoulder Injuries and Disorders

Your shoulder joint is composed of three bones: the clavicle (collarbone), the scapula (shoulder blade), and the humerus (upper arm bone). Your shoulders are the most movable joints in your body. They can also be unstable because the ball of the upper arm is larger than the shoulder socket that holds it. To remain in a stable or normal position, the shoulder must be anchored by muscles, tendons, and ligaments.

Because your shoulder can be unstable, it can be easily injured. Common problems include

Health care providers diagnose shoulder problems by using your medical history, a physical exam, and imaging tests.

Often, the first treatment for shoulder problems is RICE. This stands for Rest, Ice, Compression, and Elevation. Other treatments include exercise and medicines to reduce pain and swelling. If those don't work, you may need surgery.

NIH: National Institute of Arthritis and Musculoskeletal and Skin Diseases


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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


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Code History

  • 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 (First year ICD-10-CM implemented into the HIPAA code set)