ICD-10 Code S81.809S

Unspecified open wound, unspecified lower leg, sequela

Version 2019 Billable Code POA Exempt

Valid for Submission

S81.809S is a billable code used to specify a medical diagnosis of unspecified open wound, unspecified lower leg, sequela. The code is valid for the year 2020 for the submission of HIPAA-covered transactions.

ICD-10: S81.809S
Short Description:Unspecified open wound, unspecified lower leg, sequela
Long Description:Unspecified open wound, unspecified lower leg, sequela

Code Classification

  • Injury, poisoning and certain other consequences of external causes (S00–T98)
    • Injuries to the knee and lower leg (S80-S89)
      • Open wound of knee and lower leg (S81)

Code History

  • FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016
    (first year ICD-10-CM implemented into the HIPAA mandated code set)
  • FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
  • FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
  • FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
  • FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020

Information for Medical Professionals

Diagnostic Related Groups

The Diagnostic Related Groups (DRGs) are a patient classification scheme which provides a means of relating the type of patients a hospital treats. The DRGs divides all possible principal diagnoses into mutually exclusive principal diagnosis areas referred to as Major Diagnostic Categories (MDC). The diagnosis code S81.809S is grouped in the following groups for version MS-DRG V37.0 applicable from 10/01/2020 through 09/30/2020.

  • 604 - TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC
  • 605 - TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC

Convert S81.809S to ICD-9

The following crosswalk between ICD-10 to ICD-9 is based based on the General Equivalence Mappings (GEMS) information:

  • 906.1 - Late eff open wnd extrem (Approximate Flag)

Present on Admission (POA)

S81.809S is exempt from POA reporting - The Present on Admission (POA) indicator is used for diagnosis codes included in claims involving inpatient admissions to general acute care hospitals. POA indicators must be reported to CMS on each claim to facilitate the grouping of diagnoses codes into the proper Diagnostic Related Groups (DRG). CMS publishes a listing of specific diagnosis codes that are exempt from the POA reporting requirement.

CMS POA Indicator Options and Definitions
POA Indicator CodePOA Reason for CodeCMS will pay the CC/MCC DRG?
YDiagnosis was present at time of inpatient admission.YES
NDiagnosis was not present at time of inpatient admission.NO
UDocumentation insufficient to determine if the condition was present at the time of inpatient admission.NO
WClinically undetermined - unable to clinically determine whether the condition was present at the time of inpatient admission.YES
1Unreported/Not used - Exempt from POA reporting. NO

Synonyms

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

  • Fracture of head of fibula
  • Fracture of neck of fibula
  • Fracture of shaft of fibula
  • Fracture of shaft of fibula
  • Fracture of shaft of tibia
  • Fracture of shaft of tibia
  • Fracture of shaft of tibia and fibula
  • Fracture of tibial spine
  • Fracture of upper end of lower leg
  • Fractures involing multiple regions of upper limb
  • Fractures involving multiple regions of both lower limbs
  • Glass in lower leg
  • Glass in shin
  • Injury of anterior tibial artery
  • Injury of cutaneous sensory nerve of lower limb
  • Injury of popliteal artery
  • Injury of popliteal vein
  • Injury of tibial blood vessel
  • Injury of tibial nerve
  • Multiple open wounds of lower leg
  • Multiple open wounds of lower limb involving tendon
  • Multiple open wounds of lower limb with complication
  • Multiple open wounds with complication
  • Open bimalleolar fracture
  • Open division, superior tibiofibular ligament
  • Open fracture ankle, bimalleolar, high fibular fracture
  • Open fracture ankle, bimalleolar, low fibular fracture
  • Open fracture ankle, lateral malleolus, high
  • Open fracture ankle, lateral malleolus, low
  • Open fracture ankle, trimalleolar, high fibular fracture
  • Open fracture ankle, trimalleolar, low fibular fracture
  • Open fracture distal tibia
  • Open fracture distal tibia, extra-articular
  • Open fracture distal tibia, intra-articular
  • Open fracture fibula, head
  • Open fracture fibula, neck
  • Open fracture intercondylar spine of tibia
  • Open fracture involving multiple regions upper with lower limbs
  • Open fracture of distal fibula
  • Open fracture of distal tibia and distal fibula
  • Open fracture of fibula
  • Open fracture of lateral malleolus
  • Open fracture of lower leg
  • Open fracture of medial malleolus
  • Open fracture of multiple bones of lower limb
  • Open fracture of shaft of fibula
  • Open fracture of shaft of fibula
  • Open fracture of shaft of tibia
  • Open fracture of shaft of tibia
  • Open fracture of tibia
  • Open fracture of tibia AND fibula
  • Open fracture of tibia and fibula, shaft
  • Open fracture of tibia and/or fibula, shaft
  • Open fracture of tibial condyles
  • Open fracture of tibial plateau
  • Open fracture of tibial tuberosity
  • Open fracture of upper end of fibula
  • Open fracture of upper end of lower leg
  • Open fracture of upper end of tibia
  • Open fracture proximal tibia, bicondylar
  • Open fracture proximal tibia, lateral condyle
  • Open fracture proximal tibia, medial condyle
  • Open fractures involving multiple regions of both lower limbs
  • Open injury cutaneous sensory nerve of lower limb
  • Open injury posterior tibial nerve
  • Open injury, anterior tibial artery
  • Open injury, popliteal artery
  • Open injury, popliteal vein
  • Open pilon fracture
  • Open trimalleolar fracture
  • Open wound of knee and/or leg and/or ankle
  • Open wound of knee, leg and ankle with tendon involvement
  • Open wound of leg with complication
  • Open wound of leg with tendon involvement
  • Open wound of leg without complication
  • Open wound of lower leg
  • Open wound of lower leg with complication
  • Open wound of lower leg with tendon involvement
  • Open wound of lower limb
  • Open wound of lower limb with complication
  • Open wound of lower limb with tendon involvement
  • Open wound of lower limb without complication
  • Open wound of multiple sites of one lower limb AND thigh
  • Open wounds involving multiple regions of lower limb
  • Open wounds involving multiple regions of lower limb
  • Pilon fracture
  • Sequelae of injuries of lower limb
  • Sequelae of open wound of lower limb
  • Trimalleolar fracture

Information for Patients


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
  • Sprains and strains

[Learn More]

ICD-10 Footnotes

General Equivalence Map Definitions
The ICD-10 and ICD-9 GEMs are used to facilitate linking between the diagnosis codes in ICD-9-CM and the new ICD-10-CM code set. The GEMs are the raw material from which providers, health information vendors and payers can derive specific applied mappings to meet their needs.

  • Approximate Flag - The approximate flag is on, indicating that the relationship between the code in the source system and the code in the target system is an approximate equivalent.
  • No Map Flag - The no map flag indicates that a code in the source system is not linked to any code in the target system.
  • Combination Flag - The combination flag indicates that more than one code in the target system is required to satisfy the full equivalent meaning of a code in the source system.