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S41.002S vs S41.009S

S41.002S (Unspecified open wound of left shoulder, sequela) compared with S41.009S (Unspecified open wound of unspecified shoulder, sequela), from the official CMS tabular data. S41.002S and S41.009S code the same condition on opposite sides. MedCoder-derived

Relationship

Review

Laterality relationship

S41.002S
Left
Unspecified open wound of left shoulder, sequela
S41.009S
Unspecified
Unspecified open wound of unspecified shoulder, sequela

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. S41.002S and S41.009S 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

S41.002SUnspecified open wound of left shoulder, sequelaS41.009SUnspecified open wound of unspecified shoulder, sequela
Billing statusBillableBillable
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 left shoulder, sequela is a billable ICD-10-CM diagnosis code (S41.002S).Unspecified open wound of unspecified shoulder, sequela is a billable ICD-10-CM diagnosis code (S41.009S).
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