I'm not sure how to code this scenario. Pt recently had C-section.
S: Pt is complaining of cesarean incision since yesterday. Pt states it had been well healed and then all of a sudden noted opening yesterday. No fever, chills, pain, erythema, discharge, or warmth.
O: Abdomen is soft, nontender. Left of center about 5 mm portion that is not well approximated. No discharge, erythema, or warmth.
A/P: Superficial non-approximation of skin on left side of incision without evidence of infection.
Advised to avoid tugging at skin. Pt given ER precautions.
Provider chose this diagnosis/code: Open wound of abdominal wall, 879.2 (S31.100A).
I did some searching and found a code for "disruption of cesarean delivery wound" (S090.0), but I'm very unsure about using this. I'm also unsure about provider's chosen code, as we are told they don't always make the best choice and okay for us to code more precisely. But is this really a complication of the incision or ... ??
Thanks in advance for any advice on coding this!
S: Pt is complaining of cesarean incision since yesterday. Pt states it had been well healed and then all of a sudden noted opening yesterday. No fever, chills, pain, erythema, discharge, or warmth.
O: Abdomen is soft, nontender. Left of center about 5 mm portion that is not well approximated. No discharge, erythema, or warmth.
A/P: Superficial non-approximation of skin on left side of incision without evidence of infection.
Advised to avoid tugging at skin. Pt given ER precautions.
Provider chose this diagnosis/code: Open wound of abdominal wall, 879.2 (S31.100A).
I did some searching and found a code for "disruption of cesarean delivery wound" (S090.0), but I'm very unsure about using this. I'm also unsure about provider's chosen code, as we are told they don't always make the best choice and okay for us to code more precisely. But is this really a complication of the incision or ... ??
Thanks in advance for any advice on coding this!
