Home Health ICD-9/ICD-10 Alert

Question: We are providing daily wound care to a patient who fell and hit her shin on a concrete step several months ago. Her leg was lacerated and it hasn't healed. Since then the wound has become infected. The wound has a diagnosis of infection/non-healing ulcer, and tests positive for staph and vasculitis/microscopic polyangiitis, but it was originally a trauma wound. How should we code for this patient?


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Answer: Code this scenario as follows, suggests Laresa Boyle, RHIA, director of coding services at Longview, TX-based  Healthcarefirst:

M0230: 891.1 (Open wound of knee, leg [except thigh], and ankle, complicated);
M0240b: 041.11 (Staphylococcus aureus); and
M0240c: 446.0 (Polyarteritis nodosa).

Because this wound started out as a traumatic wound and that wound has never healed, code it as 891.1 for leg wound, complicated, says Boyle. Next, list 041.11 for the staph and then code 446.0 for the polyangiitis, she recommends.