ICD-10 Coding Tutorial: Open Wounds
Within ICD-10-CM, diagnosis codes for open wounds are categorized by:
- Site — Anatomic location on the body: Depending on the site, the information necessary to select the proper diagnosis code will differ. Some laceration and puncture wound codes are divided into “with foreign body” and “without foreign body.”
- Laterality — e.g., left or right side of the body
- Encounter (7th character extender) — Initial, subsequent, or sequela. An initial encounter is a visit for the purpose of deciding what treatment is required to repair the wound. Subsequentequates to aftercare treatment. Sequela are complications or conditions that arise as a direct result of a wound.
- Type of wound — Open wounds include:
Abrasions: Shallow, irregular wounds of the upper layers of skin. Caused by skin brushing with either a rough surface or a smooth surface at high speed. Usually present with minor to no bleeding, with some pain that subsides shortly after initial injury.
Lacerations: Tear-like wounds with irregularly torn edges that usually are deeper than abrasions, and cause more pain and bleeding. Lacerations are generally caused by trauma or contact with an object.
Incisions: Typically the result of a sharp object such as a scalpel, knife, or scissors. Mostly linear with sharp, smooth edges. Depending on the depth and site of the wound, an incision can be life threatening, especially if it involves vital organs, major blood vessels, or nerves.
Punctures: Small, rounded wounds that result from needles, nails, teeth (bites), or other tapered objects. The wound size, depth, bleeding, and pain relate to the size and force of the causative object.
Penetrating: Caused by any object or force that breaks through the skin to the underlying organs or tissue. These wounds vary in size, shape, and presentation, depending on the cause. Penetrating wounds can be life threatening, causing serious injury, especially if involving vital organs, major blood vessels, or nerves.
Gunshot wounds: These are considered to be penetrating wounds that are exclusively caused by bullets from firearms (guns, rifles, etc.). These wounds at entrance are regular, rounded, and smaller than the bullet size. The entrance wound may have a burn mark or soot on the edges and surrounding tissue, depending on the distance from which the bullet was fired. If the bullet goes all the way through the body, the exit wound will have an irregular shape that is larger than the entrance wound and usually bleeds more. Bullets move in a straight line through the body, except when they hit a bone. If they hit a bone, they can either break or shatter it, or be deflected in another direction. Aside from the risk to vital organs or major blood vessels, the fast, spinning movement of the bullet may cause serious damage to the surrounding tissue it passes through.
There are separate subcategories for unspecified open wounds, lacerations, puncture wounds, and open bites.
Main term entries in the ICD-10-CM index for open wounds can be either the type of wound (e.g., puncture), or the term wound, open. Using either term will allow the coder to find the correct type of wound and anatomical location by using the indented subterms. For example, if you look up puncture wound of the abdomen in the index using the main term Wound, openand then go to the subterms Abdomen, wall, puncture, an instructional note will guide you to “see” Puncture, abdomen, wall.
CHIEF COMPLAINT: Laceration to right leg, was escorted in by his parents
HISTORY OF PRESENT ILLNESS: This is a 4-year-old male who, approximately 45 minutes before arriving to the ER, obtained a laceration on the lateral/dorsal aspect of his right tibia/fibula areas. The mother states he has been able to walk without any difficulty, is not complaining of any pain; the only exception is whenever you touch the wound area.
PHYSICAL EXAMINATION: Patient is alert and oriented, in room playing on floor, looks to be in no apparent distress at this time.
MUSCULOSKELETAL: Is noted to have a 1.5 cm laceration to the lateral dorsal aspect of the tibia/fibula area.
ER COURSE: The wound was cleaned with Betadine solution and normal saline and dried. Dermabond was applied to wound, with edges well approximated. Then, Steri-Strips were applied to wound.
CLINICAL IMPRESSION: Leg laceration
Based on this documentation, the correct ICD-10-CM code is S81.812A Laceration without foreign body, right lower leg, initial encounter.
CHIEF COMPLAINT: Dog bite
HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old male. He states that he was breaking up a fight between the dogs and was bitten on his hands. The physician notes puncture wounds to both hands. There is no foreign body sensation. No associated numbness or tingling in the hands or fingers. The dogs are known to the patient, and the vaccination status of these dogs is also known.
EXAMINATION: GENERAL: The patient is a cooperative 46-year-old male. Alert and oriented x 3 and in no acute distress. There are puncture type lacerations that are superficial to both hands bilaterally. There is full range of motion of all the fingers with both flexion and extension. No significant body tenderness; axial loading of all the fingers is elicited. No signs of foreign body seen on the X-rays of the patient’s hands.
MEDICAL DECISION MAKING: The patient presents after a bite from dogs that were known to him; likely low risk for rabies. The puncture wounds on the patient’s hands are not gaping and I think the risks outweigh the benefits of any type of suture closure. The wounds are quite small and I think suturing them would likely increase their risk of infection.
IMPRESSION: Dog bite
PLAN: He is to follow up with his family physician for wound check in 2-3 days. He is to return to the emergency department for worsening symptoms or further concerns. I prescribed Norco 1-2 p.o. q. 4-6 hours. Augmentin 875/125 one p.o.q. 12 hours.
Proper coding is S61.431A Puncture wound without foreign body of right hand, initial encounter; S61.432A Puncture wound without foreign body of left hand, initial encounter; W54.0XXA Bitten by dog, initial encounter.