Puncture wound w/o foreign body of unsp shoulder, init

This code signifies a penetrating injury to the shoulder region, such as from a nail, needle, or sharp object, that does not involve an embedded foreign object. The wound breaches the skin and underlying tissues but the specific side of the shoulder (left or right) is not documented. This code is for the initial treatment of the injury.

Apply this code when a patient presents with a fresh puncture wound to an unspecified shoulder, and the physician's documentation explicitly states no foreign body is present. This is appropriate for the initial visit where the wound is assessed, cleaned, and potentially closed or dressed.

• Ensure documentation clearly states "no foreign body" to differentiate from codes indicating a foreign body.
• Only use the "unspecified shoulder" designation when the medical record does not specify laterality (left or right).
• The "A" suffix indicates an initial encounter for active treatment of the injury.