Open wound of scalp, without mention of complication

This code describes a break in the skin integrity of the scalp, exposing underlying tissues, that is not associated with infection, foreign body, or delayed healing. It specifically refers to an acute, uncomplicated injury where the skin is openly breached.

Use this code for traumatic injuries to the scalp such as lacerations, avulsions, or punctures, where the wound is fresh and shows no signs of complications. Documentation should clearly state "open wound of scalp" and explicitly or implicitly indicate the absence of infection, foreign body, or other specified complications.

• Do not use if there is any mention of infection, foreign body, or delayed healing; instead, select a more specific code.
• This code is for the initial encounter for an acute injury; subsequent encounters for routine follow-up without complications would typically use a different code.
• Always review documentation for depth of wound (e.g., superficial vs. deep) and associated injuries to the skull or brain, which would require additional coding.