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.

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

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John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

3 Responses to “Proper ICD-9-CM Code Selection For Injuries”

  1. Sharon Zalasin says:

    Can I get clarification on the “complicated” wound…does the provider have to document ALL of the mentioned factors? I work in an outpatient wound center, we see wounds that could be delayed in healing for maybe one or two of the mentioned reasons and for other reasons such as PVD or diabetes. I just want to be perfectly clear. Thank you.

  2. Lois M says:

    Hi Sharon:

    Since the list contains the word ‘or’ and no specific instruction that ALL must apply, I believe only one factor needs to be present for the wound to be considered ‘complicated’. My question is: does the provider need to use the word ‘complicated’ in order for the coder to code that condition.

  3. Joseph says:

    What if the multi injuries at this one site is not related to each other?

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