Wiki Open surgical wound

[shelle28]

I have a pt who is following up with their primary care physician for an ER visit for high bp. The pt also recently had a pilonidal cyst removed that the PCP mentions in the office note. The surgeon left the wound open so it could drain and heal from the inside out per PCP's note. Pt's PCP coded this as T14.8xxa which I know is wrong because this is not an injury. The PCP is doing a culture of the wound to check for infection. I am having trouble figuring out the diagnosis code to use for the surgical wound because I cannot find anything for a surgical wound that was intentionally left open - everything I come across talks about disruption of a wound. Any suggestions?

 

[dralkaahuja@yahoo.co.in]

In my opinion
I10 - should be used as the patient is primarily a case of Hypertension.
Z48.01 – Encounter for change or removal of surgical wound dressing.

As the PCP is ordering culture, it implies that he suspects infection, once the infection is confirmed T81.4XXA may be used.