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Need help with ICD-10 code please

  1. #1
    Chula Vista, CA
    Default Need help with ICD-10 code please
    Medical Coding Books
    Hi All-

    I need help, I'm not sure which way to go with this one:

    On the fee slip:

    Appt note: f/u suture in foot, wound check (I think this part is entered by the PSR?)

    Provider wrote diagnosis "healing wound"

    In the chart note:

    Reason for visit: wound check

    Note/HPI: something not legible, follow by "hit on motorcycle"

    Exam: General appearance, ENTM, neck/nodes, chest/lungs, heart: all WNL. Comment: "healing wound"

    Final dx: healing wound

    Treatment: Not legible, I couldn't make out what the provider wrote.

    I'm not sure what would be the appropriate ICD-10 code to assign. Although this states follow up, I had searched for prior visit which I didn't see. Z09 came to mind but this is not healed but rather a healing wound. I cannot locate a code for healing wound either. My other thought was to query the provider if the patient was seen for injury such as laceration, superficial, puncture and code that but what's everyone's take on this one? Any infomation is helpful and very appreciated.
    Last edited by kmikensana; 09-26-2017 at 07:27 PM.

  2. #2
    Are you able to access the billing department's ledger? It's definitely a followup to an injury code. If they want the claim to be paid, they should provide documentation. If not, there are plenty of unspecified codes I see there you can use to code for the injury as well as the motorcycle incident.

    Query someone.

  3. #3
    Columbia, MO
    You will need to use the injury S code with the seventh character of D. Per guidelines you do not use aftercare Z codes for injury and trauma. You have enough information to know this is a trauma wound you just do not know the exact injury or location. I would send the note back to the provider for additional information.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Chula Vista, CA
    Default Thank you
    That was very helpful. Have a great evening.

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