Home Health ICD-9/ICD-10 Alert

Published on Sat Sep 25, 2004 PDF

Question: We received a referral for a patient who had fallen at home and sustained a pretty severe laceration to his hand. The laceration was sutured in the ER, and sutures were later removed. A few days after removal of sutures the area reopened, leaving an open wound and the patient was then referred to home care. How would you code the wound - trauma wound, dehiscence of surgical wound, late effect of trauma wound to extremity or something else?

Answer: The best choice is 882.1 (Open wound of hand except finger[s] alone; complicated), followed by E888.9 (Unspecified fall) to describe the incident leading to the traumatic wound, Dilts-Benson advises.

Tip: If the wound had not opened, you would code V58.43 (Aftercare following surgery for injury and trauma) followed by 882.1, notes consultant Lisa Selman-Holman with Denton, TX-based Selman-Holman & Associates.

You would not code dehiscence using 998.32 (Disruption of external operation wound) because a traumatic wound remains a traumatic wound and does not become a surgical wound even when closed surgically, Dilts-Benson and Selman-Holman agree. The 906 codes (Late effects of injuries to skin and subcutaneous tissues) also don't apply, because the opening of the wound is not really a late effect, they add.