Wiki Emergency Dept dx codes laceration by knife then infection from using staple gun at home to close laceration

[tjones1106]

PLEASE HELP......I have a patient that was seen at an urgent care twice for a hand laceration done at work by a knife. Both times the urgent care told him they could not help him. He went home and used a staple gun to close his wound with 5 staples. 2-3 days later he goes to the ED and it is starting to get infected and they remove the staples. I need help with the dx codes for this emergency visit.

This is what another coder suggests and her rationale:
S61.522A laceration of the wrist with FB initial. This code happens to capture the 1st injury (plain laceration) and the 2nd injury (foreign body)
W26.0XXA contact with knife initial This is used forever when being seen for the injury. Where the pt is in the treatment phase will determine the 7th character.
W27.0XXA contact with workbench took initial This is used forever when being seen for the injury. Where the pt is in the treatment phase will determine the 7th character.
Then the home, activity and status codes. Picking these 3 codes up because he is being seen for the foreign body part of the injury for the 1st time

OR...

S60.852A-FB wrist initial
L08.9-infection
S61.522D-Laceration w/o FB subsequent (because he was seen at urgent care)
W26.0XXD-contact with knife subs (because this was what he was originally seen for)
W27.0XXA-contact with workbench tool initial for the staple gun used
Then the home, activity and status codes. Picking these 3 codes up because he is being seen for the foreign body part of the injury for the 1st time

​

 

[CPT Auditor]

This is a tough one,
in my humble opinion, and how we do things where I work
1. it is a new encounter at the facility I work at
2. I have done S61.522a + L08.9. we do not use W codes at our place of business. hope this helps

 

[nickelclaw]

I would definitely keep as an initial. I don't consider this a FB either. Saw the doc stapled it that wouldn't be considered a FB.
It is hand not wrist so I come up with S61412A, W26.0xxa, Y99.0 done at work
As for the infection need more info is it bacteria, cellulitis

 

[tjones1106]

I would definitely keep as an initial. I don't consider this a FB either. Saw the doc stapled it that wouldn't be considered a FB.
It is hand not wrist so I come up with S61412A, W26.0xxa, Y99.0 done at work
As for the infection need more info is it bacteria, cellulitis

The patient put his own staples in at home with a staple gun, Not the Dr. and that was not done at work. The original accident was at work with a knife. And yes I said hand but meant wrist, sorry that was my fault.