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Aftercare vs injury

  1. #1
    Default Aftercare vs injury
    Medical Coding Books
    A patient was referred to the Wound Care Center 10 days after receiving a laceration to his ankle. The patient received sutures in the ER at the time of injury. At the initial visit to the WCC, it was noted that the wound was healing nicely and sutures were removed. How should this be coded: aftercare, injury with encounter for removal of sutures or follow up exam? I don't feel that it should just be an encounter for removal of sutures since the wound was evaluated at the time of service. Thanks for any suggestions!!!

  2. Default
    Quote Originally Posted by Scatlot View Post
    A patient was referred to the Wound Care Center 10 days after receiving a laceration to his ankle. The patient received sutures in the ER at the time of injury. At the initial visit to the WCC, it was noted that the wound was healing nicely and sutures were removed. How should this be coded: aftercare, injury with encounter for removal of sutures or follow up exam? I don't feel that it should just be an encounter for removal of sutures since the wound was evaluated at the time of service. Thanks for any suggestions!!!
    It is an encounter for suture removal. They always have to evaluate the wound before sutures are removed. This would be just an E/M

  3. #3
    Location
    Columbia, MO
    Posts
    12,969
    Default
    if the sutures were removed and it is healing nicely then there was no wound to be examined. There is no injury any more there is just a healing scar and suture removal. you can code the
    V58.43 for aftercare following surgery for injury and trauma followed by
    V58.32 encounter for removal of sutures or staples

    Debra A. Mitchell, MSPH, CPC-H

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