Home Health ICD-9/ICD-10 Alert

Question: We recently admitted a patient with a knee abscess. When I reviewed the records, I noticed the abscess was caused by a fall. The doctor diagnosed it as an infected hematoma and performed an incision and drainage (I&D).

The patient was referred to us for wound care. According to our nurse, the wound shows no signs of infection, although the doctor has not documented this. The patient is taking antibiotics for the wound. How do I code this? I was thinking of reporting it as an abscess, but since it shows no signs of infection, using an aftercare code.


South Carolina Subscriber

Answer: The patient is likely being given antibiotics prophylactically. Hematomas put pressure on the surrounding tissues, sometimes causing necrosis. The rich environment of the hematoma encourages infection, so if bacteria can make it into the skin or joint, there's the possibility of a problem with an infection.

If the hematoma is still present, code it with 924.11 (Contusion of lower limb and of other and unspecified sites; knee).

If there is no infection and no hematoma, then you should report V58.43 (Aftercare following surgery for injury and trauma).

If the patient truly has an abscess and the abscess is still present after the I&D, code for it with 682.6 (Other cellulitis and abscess; leg, except foot) or 711.06 (Pyogenic arthritis; lower leg).

If, on the other hand, the hematoma has resulted in an abscess of the joint and the infection is still present, report:

• 711.06 (Pyogenic arthritis; lower leg) and

• 924.11 (Contusion of lower limb and of other and unspecified sites; knee).