ICD-10-CM Billable Code

S40.211

Abrasion of right shoulder

Clinical Classification Guidelines

Medical Intelligence & Overview

An abrasion of the right shoulder is a common skin injury resulting from superficial damage to the outer layers of the skin. Typically caused by friction or scraping against a rough surface, this injury often occurs during falls, accidents, or contact with abrasive objects. Recognizing the signs and understanding the management of such an injury can help in promoting proper healing and preventing complications.

Causes & Symptoms

Clinical Causes: Falling onto a rough or hard surface, causing the skin to scrape against it Accidental brushing or rubbing against abrasive materials like concrete, gravel, or rough fabrics Sports injuries, especially in activities involving falls or collisions Trauma from accidents involving machinery or sharp objects that cause superficial skin injuries Physical contact with rough objects during outdoor activities or work-related tasks

Key Symptoms: Pain or tenderness at the site of injury, which may increase with movement Superficial skin disruption — the skin appears scraped or worn away Presence of Raw or exposed tissue where the skin has been removed Minor bleeding or oozing of blood from the affected area Redness, swelling, or inflammation surrounding the abrasion Possible formation of a scab as part of the healing process Minimal swelling or bruising may also be present

Diagnostic & Treatment

Diagnosis Path: Diagnosis of an abrasion of the right shoulder is primarily clinical, based on physical examination of the skin and assessment of the injury. The healthcare provider will observe the extent of skin disruption, check for signs of infection, and determine if any debris remains embedded. In some cases, cleaning the wound and possibly taking a photo for documentation may be recommended. If there are concerns about deeper tissue involvement or damage to underlying structures, further imaging tests like ultrasound might be considered, though this is uncommon in superficial abrasions.

Treatment Protocols: Treatment for an abrasion of the right shoulder involves several steps aimed at promoting healing and preventing infection:

Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.

Clinical Advice & FAQs

Billing Guidance

Is S40.211 a billable ICD-10 code?
Yes, S40.211 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report S40.211?
Clinical documentation must specify the nature of Abrasion of right shoulder and any associated comorbidities for accurate reporting.

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