Home Health ICD-9/ICD-10 Alert

Question: We have a patient with cellulitis of the foot. Her walker fell over and hit the foot, causing a hematoma. She received an I&D for the hematoma which resulted in a large wound. She is receiving Gentamycin and requires dressing changes. The wound shows no signs of infection. How should we code for her? 



Florida Subscriber

Answer: First, you'll need to ask the physician why the patient is receiving Gentamycin when there is no infection present.

It may be that the patient is receiving the Gentamycin for the cellulitis since this condition is an infection by definition. If you verify that this is the case, report 682.7 (Other cellulitis and abscess, foot, except toes); V58.43 (Aftercare following surgery for injury and trauma); V58.3 (Attention to surgical dressings and sutures) and E916 (Struck accidentally by falling object). 

If the Gentamycin has been prescribed for use as a prophylactic, then aftercare is the focus of care and you should sequence the aftercare codes before the cellulitis. If the hematoma is still present (they often reoccur after evacuation) code it as 924.21 (Contusion of lower limb and of other and unspecified sites, ankle) or 924.20 (Contusion of lower limb and of other and unspecified sites, foot), depending on its location.