Wiki Chronic Leg wound

[kvped88@gmail.com]

We have a new patient. She is being seen for her Medicare annual wellness visit. She has a "chronic right leg wound". Apparently she has had this wound for a decade. No other explanation is given. The code given was S81.801A.

How would you code a non-healing wound that last this long? I want to go with a sequela code. Or should I be looking in an entirely different area, other than the S codes?


If anyone can offer help on this situation I would be so appreciative!

Thanks,
Kriss Pedraza, COC
LMH Health
Lawrence, KS

 

[mitchellde]

You will need more of a description explanation from the medical record. you would not use the S code unless you knew this was from trauma, and you are correct it would not be initial. I have noticed many time providers will call an abscess an open wound or ulcerations even. It is important to have as specific description as possible in order to be able to code this.