2026 ICD-10-CM Diagnosis Code S41.009DUnspecified open wound of unspecified shoulder, subsequent encounter

ICD-10-CM S41.009D

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

S41.009D is a billable ICD-10-CM diagnosis code for unspecified open wound of unspecified 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

S41.009D

Billable Status

Yes — Valid for Submission

Code Describes

Unspecified open wound of unspecified shoulder, subsequent encounter

Short Description

Unspecified open wound of unspecified shoulder, subs encntr

Parent Code

S41.009

Unspecified open wound of unspecified 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 CodeS41.009DUnspecified open wound of unspecified shoulder, subsequent encounter

Present on Admission (POA)Billing

S41.009D 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.

Filter synonyms:

Anterior dislocation of sternoclavicular joint
Anterior subluxation of sternoclavicular joint
Cut of axilla
Fracture dislocation of acromioclavicular joint
Fracture dislocation of joint of shoulder girdle
Fracture dislocation of shoulder joint
Fracture dislocation of sternoclavicular joint
Fracture of acromial process of scapula
Fracture of scapular body
Fracture subluxation of acromioclavicular joint
Fracture subluxation of shoulder joint
Fracture subluxation of sternoclavicular joint
Glass in shoulder
Multiple open wounds of shoulder
Multiple open wounds of shoulder and upper arm
Multiple open wounds of upper arm
Open dislocation of glenohumeral joint
Open dislocation of shoulder region
Open division acromioclavicular ligament
Open division coracoclavicular ligament
Open division shoulder ligament
Open division, sternal ligament
Open division, sternoclavicular ligament
Open fracture dislocation acromioclavicular joint
Open fracture dislocation of joint of shoulder girdle
Open fracture dislocation shoulder joint
Open fracture dislocation sternoclavicular joint, anterior
Open fracture dislocation sternoclavicular joint, posterior
Open fracture of acromial process of scapula
Open fracture of body of scapula
Open fracture subluxation of acromioclavicular joint
Open fracture subluxation shoulder joint
Open fracture subluxation sternoclavicular joint, anterior
Open fracture subluxation sternoclavicular joint, posterior
Open injury, suprascapular nerve
Open traumatic dislocation acromioclavicular joint
Open traumatic dislocation of glenohumeral joint, anterior
Open traumatic dislocation sternoclavicular joint
Open traumatic dislocation, sternoclavicular joint, anterior
Open traumatic dislocation, sternoclavicular joint, posterior
Open traumatic subluxation acromioclavicular joint
Open traumatic subluxation of sternum
Open traumatic subluxation shoulder joint
Open traumatic subluxation sternoclavicular joint
Open traumatic subluxation, sternoclavicular joint, anterior
Open traumatic subluxation, sternoclavicular joint, posterior
Open wound of shoulder region
Posterior dislocation of sternoclavicular joint
Shoulder fracture - open
Subluxation of acromioclavicular joint
Suprascapular nerve injury
Suprascapular nerve lesion
Suprascapular neuropathy
Traumatic dislocation of acromioclavicular joint

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

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.

Read the full article at MedlinePlus

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

Convert S41.009D 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 S41.009DOverview

Is S41.009D (Unspecified open wound of unspecified shoulder) a billable code?

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

What does the 7th character D in S41.009D mean?

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

What MS-DRG does S41.009D group to?

When unspecified open wound of unspecified 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 S41.009D 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 unspecified shoulder, subsequent encounter on inpatient claims.

What is the ICD-9 equivalent of S41.009D?

Under the General Equivalence Mappings, unspecified open wound of unspecified 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.

Indicator	Meaning	CMS pays CC/MCC DRG
Y	Diagnosis was present at the time of inpatient admission	Yes
N	Diagnosis was not present at the time of admission	No
U	Documentation is insufficient to determine	No
W	Clinically undetermined	Yes
1	Unreported, exempt from POA reporting	No