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help with wound dx code

  1. #1
    Default help with wound dx code
    Medical Coding Books
    patient has underlying hx of chronic venous insufficiency and venous stasis ulcers
    hit left lower leg on a car door sustaining a laceration 4 wks ago
    wound was sutured in ER
    pt followed up w PCP for suture removal and placed Steri-Strips which have since been removed but the wound has failed to heal

    I was thinking of......

    Does anyone have any suggestions or agree/disagree?
    Mary Beth Gord, CPC

  2. #2
    Hi Mary Beth-
    We code wound care services at my work. Based on what you have provided I would code this as 459.81, 707.10. With regards to the follow up, you could use 958.8 and the appropriate E codes. We generally use late effects E-codes and since it involved a car the E codes I would use are E9290, E8499. If you feel this will be ongoing wound care be sure to track the measurements of the wound, its appearance, odor, any associate edema, etc. as you move forward with the care. I hope this helps.

  3. #3
    Hi Mary,

    I couldcode with 891.1 - Wound complicated, since the laceration occurred 4 wks ago and still not healed. And then I would code 459.81 and 707.10 as secondary diagnosis.

    Thank You,

    Purnima S, CPC

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