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Wiki f/u healed wound

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misstigris

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I have a scenario where the patient presented to the office because she needed documentation from our provider that a dog bite she had a few months ago was healed and there was no infection or complication. We originally treated her for the bite, but it is now healed and there is no complication..

What ICD-9 code would I associate to this encounter? I have heard that it is best to indicate the original injury code (open wound of hand) but this seems strange as the injury was several months ago, we had only seen her at the original injury, and she hasn't needed any care or anything in the meantime..

Thanks
 
For what reason does she need documentation? You could possibly use a V code based on the answer to that question, such as V70.3. I don't think I would list the injury code as primary diagnosis but you could include as secondary for informational purposes. Just my opinion.:)
 
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