ICD-10-CM diagnosis code
S81.801A Unspecified open wound, right lower leg, initial encounter
- Billable
- Yes, a complete code (FY2026)
- Category
- S81 Open wound of lower leg
Encounter (7th character)
This code is for the initial encounter: the patient is receiving active treatment for the condition (for example surgery, an emergency department visit or evaluation by a new clinician).
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Other codes in S81
108 complete codes in this category.
- S81.052AOpen bite, left knee, initial encounter
- S81.052DOpen bite, left knee, subsequent encounter
- S81.052SOpen bite, left knee, sequela
- S81.059AOpen bite, unspecified knee, initial encounter
- S81.059DOpen bite, unspecified knee, subsequent encounter
- S81.059SOpen bite, unspecified knee, sequela
- S81.801AUnspecified open wound, right lower leg, initial encounter
- S81.801DUnspecified open wound, right lower leg, subsequent encounter
- S81.801SUnspecified open wound, right lower leg, sequela
- S81.802AUnspecified open wound, left lower leg, initial encounter
- S81.802DUnspecified open wound, left lower leg, subsequent encounter
- S81.802SUnspecified open wound, left lower leg, sequela
Documentation tips
- Make sure the note supports every element of the title, “Unspecified open wound, right lower leg, initial encounter”: each detail in it should be traceable to the history, examination or assessment.
- Code to the highest specificity the documentation supports. If a detail is missing from the note, add it to the note rather than choosing a less specific code by default.
- Check the Tabular List and official guidelines for instructional notes (“code first”, “use additional code”, Excludes1/Excludes2) that apply to S81.
The international WHO ICD-10 also has S81, with its inclusion and exclusion notes; titles and detail can differ from ICD-10-CM.
ICD-10-CM is developed by the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, and is based on the WHO ICD-10. Codes and titles are reproduced unchanged from the FY2026 code list (effective 1 October 2025). Their use here does not imply endorsement by CDC, HHS or the U.S. Government. Changes effective on or after 1 October 2026 may not be reflected yet; check the current release at cdc.gov or cms.gov before submitting claims.
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