Wiki Sequelae

[stephanie.henderson]

We had a new patient present with a abdominal wound that she states she has had for the past 10 years, after multiple surgeries. She is a new patient to us, and we have no documentation of her prior surgeries or what has been happening with this wound over the past several years. Our doctor originally coded this with ICD S31.109S, unspecified open wound of abdominal wall, unspecified quadrant without penetration into peritoneal cavity, sequela. I know if we use this code we also need another code to go with it.

What are your thoughts since we have no true documentation of the her past medical history?

 

[mitchellde]

You stated this was due to multiple surgeries so the code for open wound is not appropriate there is no documentation of a trauma force being applied to create the injury. if it is documented that this wound is due to the surgeries then you need a complication of surgery. the appropriate 7th character will depend on the documentation.