# wound diagnosis code - help please!!!



## mgord (Apr 20, 2010)

the documentation says the patient has a wound on the medial aspect of the rt calf, related to a local blunt injury about a month ago. Has clear fluid weeping from the anterior aspect of the calf. There is an area of skin necrosis and fluctuance in the area of the hematoma. 
Impression states "blunt trauma to right calf with hematoma and skin necrosis" and code 958.3 - posttraumatic wound infection, nec is marked. 
does anyone else agree with this code? Should I be using this 958.3 everytime we have a chronic wound that was initially caused by trauma?


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## kmhall (Apr 21, 2010)

*Post-op wound infection code*

You might look at the late effects codes.  906.X.  From what you have shown the trauma happened "a month ago".  Is it an open wound?  If so, you might need to code from the open wound w/complication section and then the late effects code.  I suppose if the wound is open because of surgery then the post-op code would be more appropriate but if the wound is open because of the trauma then the scenario I just mentioned would be more appropriate.  Maybe someone else has a better suggestion for you.  Good Luck!


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