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S41.001 vs S41.002

S41.001 (Unspecified open wound of right shoulder) compared with S41.002 (Unspecified open wound of left shoulder), from the official CMS tabular data. S41.001 and S41.002 code the same condition on opposite sides. MedCoder-derived

Relationship

Review

Laterality relationship

S41.001
Right
Unspecified open wound of right shoulder
S41.002
Left
Unspecified open wound of left shoulder

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. S41.001 and S41.002 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

S41.001Unspecified open wound of right shoulderS41.002Unspecified open wound of left shoulder
Billing statusNon-billable header

Report instead: S41.001A, S41.001D, S41.001S

Non-billable header

Report instead: S41.002A, S41.002D, S41.002S

ClassificationS00-T88 — Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88)S00-T88 — Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88)
DefinitionUnspecified open wound of right shoulder is a non-billable ICD-10-CM category code (S41.001).Unspecified open wound of left shoulder is a non-billable ICD-10-CM category code (S41.002).
7th characterThe appropriate 7th character is to be added to each code from category S41The appropriate 7th character is to be added to each code from category S41
Includes
injuries of axilla
injuries of scapular region
injuries of axilla
injuries of scapular region

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