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Wiki Trauma Wound

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clbarry8033

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

Thanks!
 
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?
 
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.
 
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).
 
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