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Thread: When to use 958.3, Posttraumatic wound infection, Vs Complicated wound code

  1. #1
    Join Date
    Apr 2007
    Martinez, CA

    Question When to use 958.3, Posttraumatic wound infection, Vs Complicated wound code

    AAPC: Back to School
    We have yet another situation where Coding Clinic, Faye Brown and Coder's Desk Reference haven't been much help. We're trying to decide when an infected traumatic wound stops being a "complicated wound" and becomes "posttraumatic."

    Generally, it seems that 958.3 is primarily used for infected burns. ICD-9 guidelines state this very clearly.

    Coding Clinic, November - December 1984 Page: 20

    Please explain when 958.3, Posttraumatic wound infection, NEC, is used.

    Patient is admitted with a wound that has not been treated and the wound is now infected. Code both the wound and the posttraumatic wound infection. Patient's wound was treated and patient now returns with infection at wound site due to failure to follow instructions on care of wound, failure to keep follow-up appointments, or due to the nature of the wound and the initial treatment, which did not entirely cleanse the wound.

    However, CDR states that 958.3 excludes infected open wounds that should be coded to complicated open wounds. "The term 'complicated' describes wounds that have delayed healing, foreign body, infection, or wounds with delayed treatment."

    Most reference material I have available points to using this code for infected burns. Infected wounds code to the appropriate complicated open wound code. Is this 1984 Coding Clinic not really applicable any more?

    I know that if the infection is due to cellulitis, we would code that and not 958.3.

    The way I am reading all of this is if a wound is still open, we code for the complicated wound. If the wound has healed but is still infected, we code the posttraumatic infection.

    I'd love to hear any thoughts on the matter.

    Brian Proosow, CCS, CPC
    The Permanente Medical Group

  2. #2


    Yes, I admit that it is a confusing and complex issue for code assignment.
    The word NEC as we understand are the ones other than those codes, which are site specific/injury/ procedural/ type/system specific etc.

    I would like to bear in mind first two major classification of wounds: 1) traumatic 2) post operative and/ or post procedural wound complications.
    Infection is one of the complications of wound, which has been mostly addressed in code assigments, in their sites/procedures like stuff.

    There are other factors also to be kept in mind like the site of the wound, type of trauma, type of surgery or procedure done, upon which the infection or complication has befallen.

    In general, (NEC) any wound of trauma origin, with infection is “post traumatic infected” wound- If you do not find a code in the particular site , then it merits to 958.3.If a wound is healed already , then it is not a wound. If the open wound is complicated with delayed healing/with a foreign body or implant/infection – wound open, with the particular site and – from the Index, select the main and subterm ,it is vast .

    If post procedural complication with infection- 998.59; If complications of obstetrical surgical wounds- 674.3x..
    This particular topic needs to be researched by the person who gets the challenge with all the available factors in the documentation.
    Does this give some clue?!

  3. #3

    Default Posttraumatic wound infection

    E code for Posttraumatic wound infection

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