Wiki Trauma Codes

[amylis1]

Report states s/p trauma ankle.
Would trauma and external code both be coded

Ex:S99912A and X581xxA?

 

[ehanna]

Report states s/p trauma ankle.
Would trauma and external code both be coded

Ex:S99912A and X581xxA?

If the external cause is given it should be coded.

 

[AlanPechacek]

Your physician needs to do a lot better than "S/P Trauma to the Ankle." That is not a "diagnosis," and he needs to come up with a "real'" and "specific" diagnosis even if it is as mild as a contusion or abrasion, or a severe injury such as a fracture.

As for the External Cause Code(s), yes all the elements of the injury need to be identified, coded, and reported for the Initial Evaluation (except for CMS/Medicare at the moment, and/or depending on the requirements of the patient's insurance company). I refer you to the Website icd10orthocoder.com and check the Coding Blogs, where I have discussed this in detail.

Respectfully submitted, Alan Pechacek, M.D.

 

[mitchellde]

I agree, s/p trauma, ankle. Tells you nothing really. Did this injury just happen, is this the initial encounter for active treatment, or is it a subsequent encounter, or is there a residual caused by the trauma. And what was the trauma as previously pointed out, is this an open wound, a fracture, a burn or a combination? And yes external causes are always invited when you can get them documented.