pain in leg due to gunshot wound

tag60

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Pt had gunshot wound in 2012. Now seen in clinic with leg pain. Provider gives dx of "pain in leg due to gunshot wound."

I've read the guidelines and still uncertain how to code this. Please tell me how you would code it. Are two dx codes needed, one for pain and one for sequela of wound? I'm also having trouble finding the code for this wound. Would "unspecified wound" of right leg be appropriate (S81.801x)? It is specified as a gunshot wound, but maybe that refers to what caused the injury, not the type of injury.

Any suggestions would be much appreciated. Thank you!
 

mitchellde

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For injuries you do use the wound code but use the 7th character S. Code the pain due to trauma G code as long as the provider has indicated this as acute or chronic. You cannot assume chronic just because the injury was in 2012. Sequence the pain code first then code the S code for the wound and the external cause code for the gunshot last with the 7th character of S.
 

tag60

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Thank you both for your replies.

To clarify -- Provider did not state if pain was chronic or acute, just "leg pain due to gunshot wound." So are you saying, Michelle, that I would code M79.606 (pain in left leg) and NOT the G code for pain due to trauma since that code specifies it as chronic pain?

M79.605, pain in left leg -- primary dx
S81.802S, unspecified open wound of left leg, sequela -- secondary dx
 

candmwalter@gmail.com

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Gunshot wound 30 years ago

Hi I have a pt with head pain pt has a history of gunshot wound to head with retained bullet and fragments due to accidental gun discharge 30 years ago. I coded the head pain I can't relate the to as the provider didn't connect it I coded head pain then coded the h/o injury to head and the retained bullet and fragments. Someone told me it should be coded headache and open wound to head with foreign body? Why the wound code and not the history? Thank you kindly Mary
 
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mitchellde

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you would not use the trauma code if the provider does not indicate the pain is due to the previous head wound. code only the pain, you can code the history of injury and the retained foreign body but you cannot link these to the pain by using the injury code with the 7th character S
 
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