Wiki Foreign Body in Knee dx

[acozzillio1123]

Help! Pt has metal foreign body in parapatellar region. Wound is technically a puncture wound but documentation states it's currently healed-over. I am torn between S81.041A and S80.251A...also, would adding code Z18.10 be appropriate? Please weigh-in and thanks in advance!

 

[amyjph]

What is the foreign body, and how long has it been in there? Is it a current injury? We would need more information I think.

Regarding Z18.10, read the Chapter 21 Official Guidelines for info.
Categories of Z codes - Status
Specifically - "A status code should not be used with a different diagnosis code from one of the body system chapters, if the diagnosis code includes the information provided by the status code."

The answers to ICD-10 questions always comes back to the guidelines.

 

[acozzillio1123]

Turns out the Z code was correct as a secondary dx code. The correct primary was M79.5 (residual foreign body in soft tissue). Tough one. Documentation said it was a piece of metal from axe blade that pt suffered when chopping wood. Pt was able to extract part of it but later (which is pretty vague) felt pain and had redness so went to ER. Physician described wound as small, punctuate, and healed-over. So I felt pretty conflicted, because technically it wasn't an open wound but not a superficial one, either. Thank you for getting back to me!