Wiki Trauma Wound

[clbarry8033]

Just wanted an opinion on how you guys would code "trauma wound rt pretib."

Thanks!

 

[mitchellde]

I would not code from that statement. I would read the note to determine the appropriate code or codes.

 

[clbarry8033]

Haha...that is the note. That is their pre and post procedure dx. They are on a Wound Care Template with little check boxes for the procedures. Any way to pull a dx from this?

 

[mitchellde]

None that I can tell. I know absolutely nothing about this injury or even if it is an injury.

 

[vjtiwari99]

Hey,

In Outpatient settings this is the usual scenario...

Right pretibial wound- S81.801A*

Hope this helps...

VJ

 

[mitchellde]

I disagree that this is usual for outpatient. I have worked outpatient and this would be considered unacceptable in every facility I have worked with. The code selected is unspecified and most likely will not be paid by most payers.

 

[CatchTheWind]

Without commenting on whether or not the note is adequate or whether or not such a vague code will be paid, I can tell you that the code for "trauma wound rt pretib" would be S81.801A (unspecified open wound, right lower leg).