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Reader Question:

Dig Deep for Infected Hematoma Code

Published on Mon Aug 13, 2012

Question: Our patient fell in a pool three weeks ago. She hit her shin on the pool deck resulting in a hematoma and subsequent infection to her leg. She was put on antibiotics to treat the infection. X-rays and a bone scan ruled out any underlying bone infection. The patient is now starting home health for wound care, following today's hematoma evacuation and placement of wound VAC. She is still finishing up last round of antibiotics.

The dilemma is how to correctly code an infected hematoma of the leg. Hematoma, as a main term, has nothing that fits. This leads me to "Contusion" which is for intact skin. I also looked at infected superficial injury (abrasion), vs. complicated trauma wound. Since this appears to be a superficial depth injury that has had significantly delayed healing and progressed to requiring more than the usual and customary treatment, would it be appropriate to code it as a complicated (infected) trauma wound of the lower leg with 891.1?

Las Vegas Subscriber

Answer: From what you describe, it appears there was no wound to begin with -- just a hematoma. Instead, it sounds like the hematoma I&D created the wound. If this is the case, and there is no mention of compartment syndrome, you would report the following codes to describe your patient's condition:

  • 924.x (Contusion of lower limb and of other and unspecified sites);
  • 958.3 (Post-traumatic wound infection, not elsewhere classified); and
  • V58.62 (Long-term [current] use of antibiotics).

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