2026 ICD-10-CM Diagnosis Code S41.002DUnspecified open wound of left shoulder, subsequent encounter

ICD-10-CM Codes›S00–T88›S40-S49›S41

ICD-10-CM S41.002D
CMSSource: CMS FY 2026 ICD-10-CM dataset · Effective Oct 1, 2025 – Sep 30, 2026

S41.002D is a billable ICD-10-CM diagnosis code for unspecified open wound of left shoulder, subsequent encounter. The 7th character D marks it as a subsequent encounter code, used during routine care in the healing or recovery phase. It is valid on HIPAA claims for fiscal year 2026 (October 1, 2025 through September 30, 2026) and groups to MS-DRG 949 through 950. The code is exempt from POA reporting. In AHRQ's Clinical Classifications Software (CCSR), this diagnosis falls under Open wounds to limbs, subsequent encounter.

Code Identity

ICD-10-CM Code
S41.002D
Billable Status
Yes — Valid for Submission
Code Describes
Unspecified open wound of left shoulder, subsequent encounter
Short Description
Unspecified open wound of left shoulder, subs encntr
Parent Code
S41.002
Unspecified open wound of left shoulder

Code Classification

ChapterS00–T88Injury, poisoning and certain other consequences of external causes
SectionS40-S49Injuries to the shoulder and upper arm
CategoryS41Open wound of shoulder and upper arm
This CodeS41.002DUnspecified open wound of left shoulder, subsequent encounter

Present on Admission (POA)Billing

S41.002D is exempt from POA reporting on inpatient claims to general acute care hospitals. Review other POA exempt codes.

Approximate SynonymsGuidance

Alternate terms and clinical phrases that map to this code.

  • Fracture of acromial end of clavicle
  • Fracture of acromial process of scapula
  • Fracture of scapular body
  • Open fracture of acromial end of clavicle
  • Open fracture of acromial end of left clavicle
  • Open fracture of acromial process of left scapula
  • Open fracture of acromial process of scapula
  • Open fracture of body of left scapula
  • Open fracture of body of scapula
  • Open fracture of clavicle
  • Open fracture of glenoid cavity of left scapula
  • Open fracture of left clavicle
  • Open fracture of left scapula
  • Open fracture scapula, glenoid
  • Open wound of left shoulder region

Coding GuidelinesGuidance

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 applicable episode of care:

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

Source: ICD-10-CM Official Guidelines for Coding and Reporting, FY 2026, published by CMS and the National Center for Health Statistics.

Clinical ClassificationClinical

AHRQ’s CCSR groups this code into broader clinical categories.

CCSR INJ049
Open wounds to limbs, subsequent encounter
Default principal diagnosis: inpatient Yes · outpatient Yes

Patient EducationClinical

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.

Read the full article at MedlinePlus

Courtesy of MedlinePlus, a service of the U.S. National Library of Medicine.

Convert S41.002D to ICD-9-CMHistory

The closest ICD-9-CM equivalents under the General Equivalence Mappings.

ICD-9-CM
V58.89 Other specfied aftercare
Approximate The match is approximate rather than exact.

Code HistoryHistory

FY 2016AddedAdded to the ICD-10-CM code setEffective October 1, 2015, the first year of ICD-10-CM.
FY 2017–2025No changes
FY 2026CurrentCurrent code set, no changesEffective October 1, 2025 through September 30, 2026.

Questions About S41.002DOverview

Is S41.002D (Unspecified open wound of left shoulder) a billable code?

Yes. This is a billable ICD-10-CM code, specific enough to report unspecified open wound of left shoulder, subsequent encounter on HIPAA-covered claims from October 1, 2025 through September 30, 2026.

What does the 7th character D in S41.002D mean?

The final character D marks a subsequent encounter: use it for routine care while the unspecified open wound of left shoulder is healing, after active treatment has ended.

What MS-DRG does S41.002D group to?

When unspecified open wound of left shoulder, subsequent encounter is the principal diagnosis on an inpatient stay, it groups to MS-DRG 949, 950, with relative weights from 0.6277 to 1.1897 depending on complications. Higher weights mean higher Medicare reimbursement.

Is S41.002D exempt from POA reporting?

Yes. CMS lists this code among those exempt from present on admission reporting, so hospitals do not assign a POA indicator for unspecified open wound of left shoulder, subsequent encounter on inpatient claims.

What is the ICD-9 equivalent of S41.002D?

Under the General Equivalence Mappings, unspecified open wound of left shoulder, subsequent encounter converts to ICD-9-CM V58.89 (other specfied aftercare). The mapping is approximate, so confirm the match fits the documentation.

Footnotes

[1] Not chronic - A diagnosis code that does not fit the criteria for chronic condition (duration, ongoing medical treatment, and limitations) is considered not chronic. Some codes designated as not chronic are acute conditions. Other diagnosis codes that indicate a possible chronic condition, but for which the duration of the illness is not specified in the code description (i.e., we do not know the condition has lasted 12 months or longer) also are considered not chronic.