Wiki Traumatic Nonhealing Wound and Sequela vs. Subsequent

[Marie A Robertshaw]

Good day, I was hoping someone could offer guidance on a sequela question. Let’s say a patient had a traumatic laceration of their right ankle over 30 days ago and returns for debridement and/or dressing care. The Wound is non-healing and there are co-morbid conditions affecting the healing. Example: chronic venous hypertension.

There is a question that since the laceration is not healing for over a month and the wound is no longer acute in nature, that this has turned into a chronic non-healing ulcer (Late effect of the laceration). Is that accurate?

If so, would this be coded as: I87.311, L97.319, S91.011S (Sequela)? Or, if the wound is not considered an ulcer, but still the laceration, S91.011D (Subsequent) would be coded instead.

There is information online that Late effects of an Open Wound is utilized for traumatic wounds or injuries which are not healing and to use a "S"

Thank you for any assistance you can provide.

 

[mitchellde]

If the wound was highly contaminated it could be ongoing continuous active treatment. It will really depends on the documentation, but I could make a case for either an A or a D. It would not be a chronic ulcer unless the provider states that it is.

 

[Marie A Robertshaw]

If the Provider is documentating that the laceration is nonhealing and is now considering the laceration to be a chronic or non-healing ulcer. Is the ulcer a true late effect of the laceration?

 

[mitchellde]

It will truely depend on how he has worded this, if the laceration is as healed as it can get and has resulted in a chronic ulcer the yes it is sequela