2026 ICD-10-CM Diagnosis Code S41.109SUnspecified open wound of unspecified upper arm, sequela
S41.109S is a billable ICD-10-CM diagnosis code for unspecified open wound of unspecified upper arm, sequela. The 7th character S marks it as a sequela code, which reports a problem that remains after the original condition has resolved. It is valid on HIPAA claims for fiscal year 2026 (October 1, 2025 through September 30, 2026) and groups to MS-DRG 604 through 605. The code is exempt from POA reporting. In AHRQ's Clinical Classifications Software (CCSR), this diagnosis falls under Injury, sequela.
Code Identity
Code Classification
Present on Admission (POA)Billing
S41.109S 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.
- Crushing injury of axillary region
- Crushing injury of upper arm
- Elbow fracture - open
- Fracture of lesser tuberosity 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
- 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 lesser tuberosity of humerus
- Open fracture of lower epiphysis of humerus
- Open fracture of medial epicondyle 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 upper arm
- Pellet wound of axilla
- Pellet wound of shoulder
- Supracondylar fracture of humerus
- Transcondylar fracture of distal humerus
- Wound of axillary 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.
Patient EducationClinical
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.
Read the full article at MedlinePlus
Courtesy of MedlinePlus, a service of the U.S. National Library of Medicine.
Convert S41.109S to ICD-9-CMHistory
The closest ICD-9-CM equivalents under the General Equivalence Mappings.
Code HistoryHistory
Questions About S41.109SOverview
Is S41.109S (Unspecified open wound of unspecified upper arm) a billable code?
Yes. This is a billable ICD-10-CM code, specific enough to report unspecified open wound of unspecified upper arm, sequela on HIPAA-covered claims from October 1, 2025 through September 30, 2026.
What does the 7th character S in S41.109S mean?
The final character S makes this a sequela code: it reports a lingering problem that remains after the unspecified open wound of unspecified upper arm itself has resolved, not the original event.
What MS-DRG does S41.109S group to?
When unspecified open wound of unspecified upper arm, sequela is the principal diagnosis on an inpatient stay, it groups to MS-DRG 604, 605, with relative weights from 0.9160 to 1.4721 depending on complications. Higher weights mean higher Medicare reimbursement.
Is S41.109S 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 upper arm, sequela on inpatient claims.
What is the ICD-9 equivalent of S41.109S?
Under the General Equivalence Mappings, unspecified open wound of unspecified upper arm, sequela converts to ICD-9-CM 906.1 (late eff open wnd extrem). 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.
