Proper ICD-9-CM Code Selection For Injuries
If a patient presents with multiple injuries, you should code for each one separately. The exception occurs if the patient has multiple injuries to the same anatomic site. In that case, you should report only the most severe injury. For example, a patient presents with a fracture and abrasion on the right elbow. You should report only the fracture because it is the most severe injury.
Codes for open wounds offer the option “without mention of complication” and “complicated.” Select the “complicated” diagnosis when the provider documents delayed healing, delayed treatment, foreign body retention, or infection.