Initial wound happened 9 months ago, never seen for it, never fully healed, now with possible cellulitis. I have two questions:
1. Is this an initial encounter or sequela?
2. Is this a superficial wound or other type?
Note as follows:
Pt noticed this morning swelling on left leg, redness on an old wound he had. Wound on left leg 9 months ago after hitting leg with bike. Wound seemed to be superficial, treated with Neosporin. Wound has not disappeared because, per mother, pt picked at it.
Exam: Left leg with 1x2 cm eschar and 10x15 cm raised area of erythema with mild warmth--probable cellulitis but has urticarial appearance.
A/P: Probable cellulitis. Given reports of fevers and vomiting, with large area of probable cellulitis, pt is referred to ER for further eval. In ER, CBC could be ordered with timely result.
Can I code as S80.922, Unspecified superficial injury of left lower leg?
And -- is this initial encounter (first time pt is seen for it, even though it's an old wound...?) or since it's an old wound, is this a sequela? I've read the AAPC blog post on initial, subsequent, or sequela, and it states it can be a sequela even if pt was never treated for it. To me, it seems it could go either way.
I'm confused! Please help!
Thanks in advance. I so appreciate all the help I get on this forum!
1. Is this an initial encounter or sequela?
2. Is this a superficial wound or other type?
Note as follows:
Pt noticed this morning swelling on left leg, redness on an old wound he had. Wound on left leg 9 months ago after hitting leg with bike. Wound seemed to be superficial, treated with Neosporin. Wound has not disappeared because, per mother, pt picked at it.
Exam: Left leg with 1x2 cm eschar and 10x15 cm raised area of erythema with mild warmth--probable cellulitis but has urticarial appearance.
A/P: Probable cellulitis. Given reports of fevers and vomiting, with large area of probable cellulitis, pt is referred to ER for further eval. In ER, CBC could be ordered with timely result.
Can I code as S80.922, Unspecified superficial injury of left lower leg?
And -- is this initial encounter (first time pt is seen for it, even though it's an old wound...?) or since it's an old wound, is this a sequela? I've read the AAPC blog post on initial, subsequent, or sequela, and it states it can be a sequela even if pt was never treated for it. To me, it seems it could go either way.
I'm confused! Please help!
Thanks in advance. I so appreciate all the help I get on this forum!