Podiatry Coding & Billing Alert

Hint: You must know if the wound is a laceration, puncture, or bite.

ICD-10-CM offers multiple codes for open wounds of the ankle. You will need to double-check the medical documentation for numerous details to select the right option. For example, you must know what type of wound the patient has, as well as the type of patient encounter.

Apply these handy tips to make sure you always submit clean open ankle wound claims in your practice.

Tip 1: Turn to These Codes for Open Wounds of Ankle

ICD-10-CM offers many codes for open wounds of the ankle. They include the following:

Unspecified wounds:

• S91.001A (Unspecified open wound, right ankle, initial encounter)-S91.001S (Unspecified open wound, right ankle, sequela)
• S91.002A (Unspecified open wound, left ankle, initial encounter)-S91.002S (Unspecified open wound, left ankle, sequela)
• S91.009A (Unspecified open wound, unspecified ankle, initial encounter)-S91.009S (Unspecified open wound, unspecified ankle, sequela)

Don’t miss: Although ICD-10-CM offers unspecified codes, you should avoid them and always check the documentation for specific details, so you can report to the highest specificity.

Lacerations:

• S91.011A (Laceration without foreign body, right ankle, initial encounter)-S91.011S (Laceration without foreign body, right ankle, sequela)
• S91.012A (Laceration without foreign body, left ankle, initial encounter)-S91.012S (Laceration without foreign body, left ankle, sequela)
• S91.019A (Laceration without foreign body, unspecified ankle, initial encounter)-S91.019S (Laceration without foreign body, unspecified ankle, sequela).
• S91.021A (Laceration with foreign body, right ankle, initial encounter)-S91.021S (Laceration with foreign body, right ankle, sequela)
• S91.022A (Laceration with foreign body, left ankle, initial encounter)-S91.002S (Laceration with foreign body, left ankle, sequela)
• S91.029A (Laceration with foreign body, unspecified ankle, initial encounter)-S91.029S (Laceration with foreign body, unspecified ankle, sequela)

Puncture wounds:

• S91.031A (Puncture wound without foreign body, right ankle, initial encounter)-S91.031S (Puncture wound without foreign body, right ankle, sequela)
• S91.032A (Puncture wound without foreign body, left ankle, initial encounter)- S91.032S (Puncture wound without foreign body, left ankle, sequela)
• S91.039A (Puncture wound without foreign body, unspecified ankle, initial encounter)-S91.039S (Puncture wound without foreign body, unspecified ankle, sequela)
• S91.041A (Puncture wound with foreign body, right ankle, initial encounter)-S91.041S (Puncture wound with foreign body, right ankle, sequela)
• S91.042A (Puncture wound, with foreign body, left ankle, initial encounter)-S91.042S (Puncture wound, with foreign body, left ankle, sequela)
• S91.049A (Puncture wound with foreign body, unspecified ankle, initial encounter)- S91.049S (Puncture wound with foreign body, unspecified ankle, sequela)

Open bites:

• S91.051A (Open bite, right ankle, initial encounter)- S91.051S (Open bite, right ankle, sequela)
• S91.052A (Open bite, left ankle, initial encounter)- S91.052S (Open bite, left ankle, sequela)
• S91.059A (Open bite, unspecified ankle, initial encounter)- S91.059S (Open bite, unspecified ankle, sequela)

Tip 2: Mind These Coding Notes

A coding note for category S91- (Open wound of ankle, foot and toes) tells you to “code also any associated wound infection.” Therefore, you should always make sure that you code for any infection of the wound.

Coding example: A patient presents to the office with a laceration of the right ankle. This is an initial encounter. There is no foreign body in the wound. The patient sustained the wound from a broken window. The wound is swollen, red, and painful, and has a yellow discharge from it. The podiatrist takes a culture of the laceration to determine possible staph infection.

You should report S91.011A (Laceration without foreign body, right ankle, initial encounter) for the laceration, along with the proper code such as B95.8 (Unspecified staphylococcus as the cause of diseases classified elsewhere) for the staph infection.

Important: The unspecified code, B95.8, is billable on your initial claim, says Jeri L Jordan, CPC, billing manager at Hampton Roads Foot and Ankle in Williamsburg, Virginia. However, for follow-up visits, you would use the results from the lab for a more specific code. Also, you should never report B95.8 as the primary diagnosis.

You should also report W25.XXXA (Contact with sharp glass, initial encounter) as the external cause code. When using an external cause code, never report it as the primary diagnosis, Jordan explains. You may use more than one external cause code if needed, such as W18.02XA (Striking against glass with subsequent fall, initial encounter) if it happened with a subsequent fall.

Tip 3: Ask Yourself These Questions

As you can see from the above code descriptors, when you report open wounds of the ankle, you must know many details, such as whether the right or left ankle was affected.

Take a look at the questions you should keep in mind when reporting open wounds of the ankle:

• Which ankle was affected? Right or left?
• What type of encounter was this? Initial, subsequent, or sequela?
• What caused the wound: a laceration, puncture, or open bite?
• If it was a laceration or puncture, was there a foreign body?
• Was there any associated wound infection?