Version 2024

2024 ICD-10-CM Diagnosis Code S21.90XA

Unspecified open wound of unspecified part of thorax, initial encounter

ICD-10-CM Code:: S21.90XA
ICD-10 Code for:: Unsp open wound of unspecified part of thorax, init encntr
Is Billable?: Yes - Valid for Submission
Chronic Condition Indicator: ^[1]: Not chronic
Code Navigator:

Code Information
Approximate Synonyms
Clinical Classification
Clinical Information
Coding Guidelines
Tabular List of Diseases and Injuries
Code Edits
Diagnostic Related Groups Mapping
Convert to ICD-9 Code
Patient Education
Other Codes Used Similar Conditions
Code History

Code Classification

Injury, poisoning and certain other consequences of external causes
(S00–T88)
- Injuries to the thorax
  (S20-S29)
  - Open wound of thorax
    (S21)

S21.90XA is a billable diagnosis code used to specify a medical diagnosis of unspecified open wound of unspecified part of thorax, initial encounter. The code is valid during the current fiscal year for the submission of HIPAA-covered transactions from October 01, 2023 through September 30, 2024.

S21.90XA is an initial encounter code, includes a 7th character and should be used while the patient is receiving active treatment for a condition like unspecified open wound of unspecified part of thorax. According to ICD-10-CM Guidelines an "initial encounter" doesn't necessarily means "initial visit". The 7th character should be used when the patient is undergoing active treatment regardless if new or different providers saw the patient over the course of a treatment. The appropriate 7th character codes should also be used even if the patient delayed seeking treatment for a condition.

Unspecified diagnosis codes like S21.90XA 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.

Approximate Synonyms

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

Acute lung injury
Burst fracture of thoracic vertebra
Closed injury of lung
Complete spinal cord injury at T1-T6 level
Complete spinal cord injury at T7-T12 level
Contusion of lung
Contusion of lung with open wound into thorax
Contusion to heart
Contusion to heart with open wound into thorax
Direct acute lung injury
Dislocation of costovertebral joint
Extravasation injury
Extravasation injury
Fracture of eight OR more ribs
Fracture of five ribs
Fracture of four ribs
Fracture of left rib
Fracture of left rib
Fracture of left rib
Fracture of one rib
Fracture of one rib
Fracture of one rib
Fracture of right rib
Fracture of right rib
Fracture of right rib
Fracture of seven ribs
Fracture of six ribs
Fracture of spinous process of thoracic vertebra
Fracture of three ribs
Fracture of transverse process of thoracic vertebra
Fracture of two ribs
Fractures involving thorax with lower back and pelvis
Fractures involving thorax with lower back and pelvis with limb
Glass in chest
Glass in trunk
Heart injury, closed
Heart injury, open
Heart injury, open
Heart laceration with open wound into thorax, with penetration of heart chambers
Hemopericardium
Hemopneumothorax
Hemothorax
Hemothorax
Injury of bronchus with open wound into thoracic cavity
Injury of cervical esophagus
Injury of cutaneous sensory nerve of upper limb
Injury of diaphragm with open wound into cavity
Injury of esophagus with open wound into thoracic cavity
Injury of heart with hemopericardium
Injury of heart with open wound into thorax
Injury of heart with open wound into thorax
Injury of intercostobrachial nerve
Injury of lung with open wound into thorax
Injury of lung with open wound into thorax
Injury of pleura
Injury of subclavian artery
Injury of subclavian vein
Injury of thoracic cavity
Injury of thoracic cavity
Injury of thoracic cavity
Injury of thoracic cavity
Injury of thoracic cavity
Injury of thoracic cavity
Injury of thoracic cavity
Injury of thoracic cavity
Injury of thoracic duct
Injury of thoracic trachea
Injury of thymus gland
Laceration of heart
Laceration of heart with penetration of heart chambers
Laceration of lung
Long thoracic nerve injury
Long thoracic nerve lesion
Lung laceration with open wound into thorax
Multiple fractures of upper limb with sternum
Multiple injuries of intrathoracic organs
Multiple injuries of thorax
Multiple intrathoracic organ injury with open wound into cavity
Multiple open wounds of thoracic wall
Open bilateral fracture of multiple ribs
Open division of ligament of thoracic vertebral column
Open division, chondrosternal ligament
Open division, costal cartilage ligament
Open division, rib ligament
Open division, sternal ligament
Open fracture involving thorax with lower back and pelvis and limbs
Open fracture of eight OR more ribs
Open fracture of five ribs
Open fracture of four ribs
Open fracture of multiple left ribs
Open fracture of multiple ribs
Open fracture of multiple right ribs
Open fracture of multiple right ribs
Open fracture of one left rib
Open fracture of one rib
Open fracture of one rib
Open fracture of one rib
Open fracture of one right rib
Open fracture of seven ribs
Open fracture of six ribs
Open fracture of T1-T6 level with anterior cord syndrome
Open fracture of T1-T6 level with central cord syndrome
Open fracture of T1-T6 level with posterior cord syndrome
Open fracture of T1-T6 level with spinal cord injury
Open fracture of T1-T6 level with spinal cord injury
Open fracture of T1-T6 level with spinal cord injury
Open fracture of T1-T6 level with spinal cord injury
Open fracture of T1-T6 level with spinal cord injury
Open fracture of T1-T6 level with spinal cord injury
Open fracture of T1-T6 level with spinal cord injury
Open fracture of T7-T12 level with incomplete spinal cord lesion
Open fracture of T7-T12 level with posterior cord syndrome
Open fracture of T7-T12 level with spinal cord injury
Open fracture of T7-T12 level with spinal cord injury
Open fracture of T7-T12 level with spinal cord injury
Open fracture of T7-T12 level with spinal cord injury
Open fracture of three ribs
Open fracture of two ribs
Open fracture thoracic vertebra
Open fracture thoracic vertebra, burst
Open fracture thoracic vertebra, posterior arch
Open fracture thoracic vertebra, spinous process
Open fracture thoracic vertebra, spondylolysis
Open fracture thoracic vertebra, transverse process
Open fracture thoracic vertebra, tricolumnar
Open fracture thoracic vertebra, wedge
Open heart injury with hemopericardium
Open injury of bronchus
Open injury of diaphragm
Open injury of intercostobrachial nerve
Open injury of lung
Open injury of lung
Open injury of lung
Open injury of pleura
Open injury of thoracic duct
Open injury of thoracic trachea
Open injury of thymus
Open injury, long thoracic nerve
Open injury, subclavian artery
Open injury, subclavian vein
Open multiple fracture of thoracic spine
Open multiple fractures of upper limb with sternum
Open spinal fracture with anterior thoracic cord lesion, T1-6
Open spinal fracture with complete thoracic cord lesion, T1-6
Open spinal fracture with complete thoracic cord lesion, T7-12
Open spinal fracture with posterior thoracic cord lesion, T1-6
Open spinal fracture with posterior thoracic cord lesion, T7-12
Open traumatic dislocation costovertebral joint
Open traumatic dislocation of costochondral joint
Open traumatic subluxation costovertebral joint
Open traumatic subluxation of costochondral joint
Open wound of cervical esophagus without complication
Open wound of chest wall, uncomplicated
Open wound of neck without complication
Open wound of thorax
Open wound of throat without complication
Open wound of trachea
Open wounds involving thorax with abdomen, lower back and pelvis
Penetrating wound of lung
Spondylolysis of thoracic vertebra
Subluxation of costochondral joint
Subluxation of costovertebral joint
Three column fracture of thoracic vertebra
Traumatic anterior cord syndrome
Traumatic hemopericardium
Traumatic hemothorax
Traumatic hemothorax
Traumatic hemothorax with open wound into thorax
Traumatic hemothorax with open wound into thorax
Traumatic pneumohemothorax
Traumatic pneumohemothorax with open wound into thorax
Traumatic pneumothorax
Traumatic pneumothorax
Traumatic pneumothorax with open wound into thorax
Traumatic pneumothorax with open wound into thorax
Wedge fracture of thoracic vertebra
Wedge fracture of vertebra

Clinical Classification

Clinical Category is Open wounds of trunk, initial encounter
CCSR Category Code: INJ013
Inpatient Default CCSR: Y - Yes, default inpatient assignment for principal diagnosis or first-listed diagnosis.
Outpatient Default CCSR: Y - Yes, default outpatient assignment for principal diagnosis or first-listed diagnosis.

Clinical Information

Hemopneumothorax
collection of air and blood in the pleural cavity.
Acute Lung Injury
a condition of lung damage that is characterized by bilateral pulmonary infiltrates (pulmonary edema) rich in neutrophils, and in the absence of clinical heart failure. this can represent a spectrum of pulmonary lesions, endothelial and epithelial, due to numerous factors (physical, chemical, or biological).
Transfusion-Related Acute Lung Injury
a rare but serious transfusion-related reaction in which fluid builds up in the lungs unrelated to excessively high infusion rate and/or volume (transfusion-associated circulatory overload). signs of transfusion-related acute lung injury include pulmonary secretions; hypotension; fever; dyspnea; tachypnea; tachycardia; and cyanosis.
Hemothorax
hemorrhage within the pleural cavity.
Hemopericardium
an accumulation of blood within the pericardial sac.

Coding Guidelines

The appropriate 7th character is to be added to each code from block Open wound of thorax (S21). Use the following options for the aplicable episode of care:

A - initial encounter
D - subsequent encounter
S - sequela

Code Edits

The Medicare Code Editor (MCE) detects and reports errors in the coding of claims data. The following ICD-10-CM Code Edits are applicable to this code:

Unspecified codes - Unspecified codes exist in the ICD-10-CM classification for circumstances when documentation in the medical record does not provide the level of detail needed to support reporting a more specific code. However, in the inpatient setting, there should generally be very limited and rare circumstances for which the laterality (right, left, bilateral) of a condition is unable to be documented and reported. The following pages contain the list of unspecified ICD-10-CM diagnosis codes for which there is a more specific code to identify laterality (right, left, bilateral) within that code family.

S21.90XA is grouped with Diagnostic Related Groups - MS-DRG Mapping

Diagnostic Related Groups (DRGs) are a classification system used to group together diagnosis codes for the purpose of reimbursement and healthcare management. DRGs are used to standardize the way hospitals and other providers are paid for inpatient services. In this system patients are grouped together based on their principal diagnosis in areas referred to as Major Diagnostic Categories (MDC). Once a patient is assigned a particular diagnostic category, providers receive a predetermined payment rate for the services rendered. This reimbursement rate is often fixed and is meant to cover the cost of care for that patient. Reimbursement is also affected by the relative weight of a diagnostic related group based on the severity of a patient's illness and the associated cost of care during hospitalization.

Diagnostic related groups encourage healthcare providers to focus on quality and efficiency in patient care while managing costs effectively. The diagnosis code is present in the following groups for version MS-DRG V41.0 applicable from 10/01/2023 through 09/30/2024.

MS-DRG	MS-DRG Title	MCD	Relative Weight
604	TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC	09	1.5062
605	TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC	09	0.9088

The relative weight of a diagnostic related group determines the reimbursement rate based on the severity of a patient's illness and the associated cost of care during hospitalization.

Convert S21.90XA to ICD-9-CM

ICD-9-CM Code: 875.0 - Open wound of chest
Approximate Flag - The approximate mapping means there is not an exact match between the ICD-10 and ICD-9 codes and the mapped code is not a precise representation of the original code.

Patient Education

Chest Injuries and Disorders

What is the chest?

The chest is the part of your body between your neck and your abdomen (belly). The medical term for your chest is thorax.

Your chest holds many important structures for breathing, digestion, blood circulation, and other important body functions. These structures include your:

Ribs and breastbone
Esophagus, the tube between your mouth and stomach
Trachea, your windpipe
Bronchi, the tubes that carry air from your windpipe to your lungs
Lungs
Pleura, a thin layer of tissue that covers the lungs and lines the inside wall of the chest space
Heart and large blood vessels
Thymus, a gland that's part of your immune system
Nerves

What are chest injuries and disorders?

Chest injuries and disorders are problems that affect any of the organs or structures located in your chest.

There are many types of chest injuries and disorders, for example:

Broken ribs
Esophagus disorders
Swallowing disorders, also called dysphagia
Tracheal disorders
Bronchial disorders
Lung diseases and collapsed lung
Pleural disorders
Heart diseases
Mediastinal diseases, which are tumors, inflammation, and other problems with the structures in the mediastinum, which is the space between your lungs, breastbone, and spine
Thoracic aortic aneurysm
Thoracic outlet syndrome

Chest injuries may happen from the force of car accidents, falls, or sports injuries. Or the chest may be pierced by a bullet or sharp object. Because your chest holds so many important structures, certain chest injuries may be life-threatening.

How are chest injuries and disorders diagnosed?

Diagnosis of chest injuries or disorders depends on the type of symptoms you're having and whether you've had a chest injury. Injuries are usually obvious, but in most cases, you'll need tests to know how serious an injury is.

There are many types of tests for diagnosing different types of chest injuries and disorders, for example:

Diagnostic imaging tests
Heart tests
Lung function tests
Bronchoscopy
Pleural fluid analysis
Dysphagia tests
Biopsy

Treatments will depend on the type of chest injury or disorder you have.

[Learn More in MedlinePlus]

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 (broken bones)
Sprains and strains

[Learn More in MedlinePlus]

Other ICD-10-CM Codes Commonly Used for Similar Conditions

Filter related codes list:

S21 Open wound of thorax.
S21.0 Open wound of breast.
S21.00 Unspecified open wound of breast.
S21.001 Unspecified open wound of right breast.
S21.001A Unspecified open wound of right breast, initial encounter.
S21.001D Unspecified open wound of right breast, subsequent encounter.
S21.001S Unspecified open wound of right breast, sequela.
S21.002 Unspecified open wound of left breast.
S21.002A Unspecified open wound of left breast, initial encounter.
S21.002D Unspecified open wound of left breast, subsequent encounter.
S21.002S Unspecified open wound of left breast, sequela.
S21.009 Unspecified open wound of unspecified breast.
S21.009A Unspecified open wound of unspecified breast, initial encounter.
S21.009D Unspecified open wound of unspecified breast, subsequent encounter.
S21.009S Unspecified open wound of unspecified breast, sequela.
S21.01 Laceration without foreign body of breast.
S21.011 Laceration without foreign body of right breast.
S21.011A Laceration without foreign body of right breast, initial encounter.
S21.011D Laceration without foreign body of right breast, subsequent encounter.
S21.011S Laceration without foreign body of right breast, sequela.
S21.012 Laceration without foreign body of left breast.
S21.012A Laceration without foreign body of left breast, initial encounter.
S21.012D Laceration without foreign body of left breast, subsequent encounter.
S21.012S Laceration without foreign body of left breast, sequela.
S21.019 Laceration without foreign body of unspecified breast.
S21.019A Laceration without foreign body of unspecified breast, initial encounter.
S21.019D Laceration without foreign body of unspecified breast, subsequent encounter.
S21.019S Laceration without foreign body of unspecified breast, sequela.
S21.02 Laceration with foreign body of breast.
S21.021 Laceration with foreign body of right breast.
S21.021A Laceration with foreign body of right breast, initial encounter.
S21.021D Laceration with foreign body of right breast, subsequent encounter.
S21.021S Laceration with foreign body of right breast, sequela.
S21.022 Laceration with foreign body of left breast.
S21.022A Laceration with foreign body of left breast, initial encounter.
S21.022D Laceration with foreign body of left breast, subsequent encounter.
S21.022S Laceration with foreign body of left breast, sequela.
S21.029 Laceration with foreign body of unspecified breast.
S21.029A Laceration with foreign body of unspecified breast, initial encounter.
S21.029D Laceration with foreign body of unspecified breast, subsequent encounter.
S21.029S Laceration with foreign body of unspecified breast, sequela.
S21.03 Puncture wound without foreign body of breast.
S21.031 Puncture wound without foreign body of right breast.
S21.031A Puncture wound without foreign body of right breast, initial encounter.
S21.031D Puncture wound without foreign body of right breast, subsequent encounter.
S21.031S Puncture wound without foreign body of right breast, sequela.
S21.032 Puncture wound without foreign body of left breast.
S21.032A Puncture wound without foreign body of left breast, initial encounter.
S21.032D Puncture wound without foreign body of left breast, subsequent encounter.
S21.032S Puncture wound without foreign body of left breast, sequela.
S21.039 Puncture wound without foreign body of unspecified breast.

Code History

FY 2024 - No Change, effective from 10/1/2023 through 9/30/2024
FY 2023 - No Change, effective from 10/1/2022 through 9/30/2023
FY 2022 - No Change, effective from 10/1/2021 through 9/30/2022
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. This was the first year ICD-10-CM was implemented into the HIPAA code set.

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.