Primary Care Coding Alert

Question: Our physician treated a soft-tissue infection on a patient's finger. Which diagnosis code should we report for this?

South Carolina Subscriber Answer: It depends on the type of finger infection the patient had. For instance, if the physician describes cellulitis to the skin on the finger, you should report one of three codes:

- 681.00 -- Cellulitis and abscess of finger and toe;   finger; unspecified

- 681.01 -- - felon

- 681.02 -- - onychia and paronychia of finger. You should also use an additional code to identify the organism, such as 041.x (Bacterial infection in conditions classified elsewhere and of unspecified site).

However, if the physician is treating an infection to a soft tissue other than the skin, you could report 728.89 (Other disorders of muscle, ligament, and fascia; other). Further, if the infection is of unknown origin or cannot be classified into one of these categories, you might consider 686.9 (Unspecified local infection of skin and subcutaneous tissue).

Ask if you need to: If the documentation does not reveal the type of infection or how deep it was, you should ask the physician for more details.