Wiki 729.6 or 894.1

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tmorehart

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Hello all,

I am new to ortho coding and I am trying to come up with the most appropriate dx code for this encounter.

Patient has a nail in his leg from injury on 4/27, went to ER on 4/29 and now ortho is seeing him for followup on 5/1.

Should I report a 729.6(old foreign body in soft tissue), V90.10(retained metal fragment NOS) or a 894.1(Open wound leg NEC-Complicated), V90.10?

My supervisor asked me to get some feedback on this from other ortho coders so any input would be greatly appreciated!

Thank you
 
what was done in the ER? if the performed surgery and you are now providing the followup the use the V code for followup following surgery for injury or trauma. You do not code the injury as it is no longer acute. You can add the V code for the retained foreign body.
 
No surgery done in ER. The patient denied surgery and they gave him antibiotics. He is now being seen for followup in the ortho clinic and they scheduled surgery at this ortho clinic visit.
 
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