S91

Header — not billable

Open wound of ankle, foot and toes

The ICD-10 code for open wound of ankle, foot and toes is S91.

S91 is a non-billable header code. It groups related conditions but cannot be used on its own for reimbursement — select one of the 4 more specific codes below.

Clinical notes

Code also

Two codes may be needed to fully describe a condition, but unlike Code First/Use Additional Code, the sequencing order is not mandated by convention.

any associated wound infection

Excludes1 (not coded here)

An Excludes1 note is a pure exclusion: the excluded condition and this code should never be reported together, because the two conditions cannot occur at the same time (e.g. a congenital form vs. an acquired form of the same disease).

open fracture of ankle, foot and toes (S92.-with 7th character B)
traumatic amputation of ankle and foot (S98.-)

7th character definitions

These definitions specify what each valid 7th-character value means for codes in this category.

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7th character note

This category requires a 7th character to indicate additional clinical detail (e.g. encounter type: initial, subsequent, sequela). The code is incomplete without it.

The appropriate 7th character is to be added to each code from category S91

Documentation support

General coding-documentation guidance — not a substitute for payer-specific requirements or professional coding judgment.

•This is a non-billable header code. Documentation must support a more specific child code before this diagnosis can be reported on a claim.
•Confirm the excluded condition(s) listed above are not also present — Excludes1 conditions cannot be coded together with this one.
•This category requires a 7th character. Documentation should clearly indicate the episode of care (initial encounter, subsequent encounter, or sequela).
•As a general rule, code to the highest level of specificity supported by the documentation in the medical record.

S91