Question

rom the health record of a patient undergoing foot surgery in the outpatient surgical unit:
Indication for Procedure: The patient is a 60-year-old female who has a persistently
ingrowing great toenail on the left foot that has had two past infections. The infection
is now clear and the patient presents for wedge resection of the toenail. She also
has pernicious anemia, Friedreich's ataxia, and heart disease. Because of these
conditions, a digital block will be used for the procedure.
Procedure: Wedge resection of toenail
Procedure Description: The patient is placed in the supine position, with the knees
flexed, and the left foot is flat on the table. The toe is prepped and cleansed. A standard
digit block is performed with 1 percent lidocaine using a 10-ml syringe and a 30-gauge
needle. Approximately 3 ml is instilled on each side of the toe.
After waiting 10 minutes, a sterilized rubber band is placed around the base of the toe.
The toe is resterilized and draped with the toe protruding. A nail elevator is slid under
the cuticle to separate the nail plate from the overlying proximal nail fold, The lateral
one fourth of the nail plate is identified as the site for the partial lateral nail removal.
A bandage scissors is used to cut from the distal end of the nail straight back beneath
the proximal nail fold. A straight, smooth, new lateral edge to the nail plate is created.
The lateral piece of nail is grasped with a hemostat and removed in one piece, pulling
straight out.

ICD-10-CM and CPT Code(s):

Answer 1

Unspecified open wound of unspecified toe(s) with damage to nail, initial encounter

S91.209A is a specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.

S00-T88 Injury, poisoning and certain other consequences of external causes

• S90-S99 Injuries to the ankle and foot
• S91 Open wound of ankle, foot and toes

Approximate Synonyms

• Avulsion of left toenail
• Avulsion of right toenail
• Avulsion of toenail
• Left toenail avulsion
• Right toenail avulsion

ICD-10-CM S91.209A is grouped within Diagnostic Related Group(s)

• 604 Trauma to the skin, subcutaneous tissue and breast with mcc
• 605 Trauma to the skin, subcutaneous tissue and breast without mcc
• 955 Craniotomy for multiple significant trauma
• 956 Limb reattachment, hip and femur procedures for multiple significant trauma
• 957 Other o.r. Procedures for multiple significant trauma with mcc
• 958 Other o.r. Procedures for multiple significant trauma with cc
• 959 Other o.r. Procedures for multiple significant trauma without cc/mcc
• 963 Other multiple significant trauma with mcc
• 964 Other multiple significant trauma with cc
• 965 Other multiple significant trauma without cc/mccmcc

The patient is placed in the supine position, with the kneesflexed, and the left foot is flat on the table. The toe is prepped and cleansed. A standarddigit block is performed with 1 percent lidocaine using a 10-ml syringe and a 30-gaugeneedle. Approximately 3 ml is instilled on each side of the toe.After waiting 10 minutes, a sterilized rubber band is placed around the base of the toe.The toe is resterilized and draped with the toe protruding. A nail elevator is slid underthe cuticle to separate the nail plate from the overlying proximal nail fold, The lateralone fourth of the nail plate is identified as the site for the partial lateral nail removal.A bandage scissors is used to cut from the distal end of the nail straight back beneath the proximal nail fold. A straight, smooth, new lateral edge to the nail plate is created.The lateral piece of nail is grasped with a hemostat and removed in one piece, pulling straight out.