Patient presents to ED with knee pain and swelling, S/P laceration repair 3 days ago.
Clinical Impression is "infected laceration repair, right knee."
From what I'm reading (granted, it is an ICD-9 Coding Clinic), the coder "should assume that the wound is the problem and the source of the infection rather than the surgical technique" IN THE ABSENCE OF ANY DOCUMENTATION TO THE CONTRARY.
Because he clearly says "infected laceration REPAIR," am I okay to code to "Infection following a procedure, initial encounter" (T81.4xxA) with secondary of "local infection of the skin and subcutaneous tissue, unspecified" (L08.9) to identify infection?
Am I interpreting and applying this correctly?
Do I require a code for the active treatment (subsequent encounter?) of the original open wound? Otherwise, you really have no idea WHERE the original wound was. However, definition of "subsequent encounter" states "receiving ROUTINE CARE" during the healing phase. Since it's infected, it would no longer be "routine care," I wouldn't think.
Subsequent encounter (7th character 'D'): Used for encounters after active treatment for the injury has been provided and is receiving routine care during the healing or recovery phase. Examples of subsequent care: ...wound check...and follow up visits following injury treatment.
Thank you!
Clinical Impression is "infected laceration repair, right knee."
From what I'm reading (granted, it is an ICD-9 Coding Clinic), the coder "should assume that the wound is the problem and the source of the infection rather than the surgical technique" IN THE ABSENCE OF ANY DOCUMENTATION TO THE CONTRARY.
Because he clearly says "infected laceration REPAIR," am I okay to code to "Infection following a procedure, initial encounter" (T81.4xxA) with secondary of "local infection of the skin and subcutaneous tissue, unspecified" (L08.9) to identify infection?
Am I interpreting and applying this correctly?
Do I require a code for the active treatment (subsequent encounter?) of the original open wound? Otherwise, you really have no idea WHERE the original wound was. However, definition of "subsequent encounter" states "receiving ROUTINE CARE" during the healing phase. Since it's infected, it would no longer be "routine care," I wouldn't think.
Subsequent encounter (7th character 'D'): Used for encounters after active treatment for the injury has been provided and is receiving routine care during the healing or recovery phase. Examples of subsequent care: ...wound check...and follow up visits following injury treatment.
Thank you!
"Infected laceration repair"
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