Laceration of muscle and tendon of head, initial encounter

This code signifies a traumatic injury involving a cut or tear to the muscular and/or tendinous tissues located in the head region. This injury penetrates the skin and underlying soft tissues, affecting the functional components responsible for head movement or facial expression.

Apply this code for initial treatment of an open wound to the head that explicitly documents involvement of muscle or tendon. This includes scenarios such as deep cuts from trauma (e.g., falls, assaults, motor vehicle accidents) where the injury extends beyond the skin and subcutaneous tissue to damage muscle fibers or tendons. Documentation must clearly specify "laceration" and "muscle" or "tendon" involvement.

• Ensure documentation specifies "initial encounter" for the treatment of this specific injury. Subsequent care would use a different encounter character.
• Distinguish from superficial lacerations (e.g., S01.81XA) or those only involving skin and subcutaneous tissue, which do not specify muscle/tendon involvement.
• Always code the external cause of the injury (e.g., W00-Y38) in addition to the laceration code.