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S21.001 vs S21.009

S21.001 (Unspecified open wound of right breast) compared with S21.009 (Unspecified open wound of unspecified breast), from the official CMS tabular data. S21.001 and S21.009 code the same condition on opposite sides. MedCoder-derived

Relationship

Review

Laterality relationship

S21.001
Right
Unspecified open wound of right breast
S21.009
Unspecified
Unspecified open wound of unspecified breast

Same condition; these differ only in which side is documented.

These codes share a category and title and differ only in the side affected. The documentation decides which applies, and a bilateral code is reported only where the code set provides one.

Source: ICD-10-CM tabular list (laterality variant derived from the code title)

Can these codes be reported together?

Same condition, opposite side. S21.001 and S21.009 name the same condition on opposite sides of the body.

Same category and title, differing only in which side is affected — the documentation decides which one applies, and a bilateral code is reported only where the code set provides one.

Side by side

S21.001Unspecified open wound of right breastS21.009Unspecified open wound of unspecified breast
Billing statusNon-billable header

Report instead: S21.001A, S21.001D, S21.001S

Non-billable header

Report instead: S21.009A, S21.009D, S21.009S

ClassificationS00-T88 — Injury, poisoning and certain other consequences of external causesS00-T88 — Injury, poisoning and certain other consequences of external causes
DefinitionUnspecified open wound of right breast is a non-billable ICD-10-CM category code (S21.001).Unspecified open wound of unspecified breast is a non-billable ICD-10-CM category code (S21.009).
7th characterThe appropriate 7th character is to be added to each code from category S21The appropriate 7th character is to be added to each code from category S21
Includes
injuries of breast
injuries of chest (wall)
injuries of interscapular area
injuries of breast
injuries of chest (wall)
injuries of interscapular area

Derived from the official CMS ICD-10-CM tabular data (FY2026). Not billing advice; verify sequencing rules for the encounter. All data sources