Wiki Dx E-code issue

she803

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Physican coded this report with dx E906.5. E-codes are never coded primary but based on this report what should the primary code be since it indicates no fracture or dislocation from the animal bite?

History: Mouse bite to the dorsal surface of right foot below fourth digits 4 days ago.

Exam: 3 views of the right foot obtained 4/15/2012. There are no prior studies available for comparison at this institution.

Findings:

There is no fracture or dislocation. There is an 11 mm needlelike linear radiopaque density which is overlying the soft tissues of the third digit on the AP view and overlies the plantar soft tissues of the proximal digits on the lateral view. Soft tissue edema is noted along the dorsum of the mid and hindfoot. Degenerative changes are noted and mid foot. A small heel spur is noted.
 
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