Help with Code for Wound Infection

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elizabeth24

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We see this scenario a lot in our ER.... patient comes in with a puncture or laceration to finger and it is infected. In ICD-9 we used code 883.1, which was an open wound, complicated, and the complicated option covered a "wound infection". This option no longer exists with ICD-10.

Any ideas on the appropriate way to code this?

Thanks!
 
Looking in the ICD-10 book. Its an S62.- code primary and code Wound infection DX separately. The following looks like it might be an appropriate secondary dx, L08.89 - Other specified local infections of the skin and subcutaneous tissue
 
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I wasn't sure if you used the S62. - or if you would use T79.8xxA - early complications due to trauma.... any thoughts?
 
GEMS file record for 883.1 led me to S62.- Laceration, finger w/ foreign body not involving nail. Doing index in ICD-10 Laceration finger led to S61.- which is without foreign body not involving nail. Most of the laceration listings in the index lead me to similar codes. looking at codes on the pages before or after its with or without nail involvement and with or without foreign body.

Looking at the S-T guidelines T codes should not be used if there is a single body area involved:

Notes: The chapter uses the S-section for coding different types of injuries related to single body regions and the T-section to cover injuries to unspecified body regions as well as poisoning and certain other consequences of external causes.
 
open wound with infection

I'm wondering how to code the wound infection in this scenario from the ED...

Chief Complaint:
Patient presents with Foot Pain Arm Pain

HPI:
21-year-old male brought in by grandmother for evaluation of possible wound infections. The patient was involved in a motor vehicle collision 10 days ago and sustained apparent traumatic brain injury as well as some ligamentous injuries to his feet. He had repair of laceration to his right elbow but has various cuts and scrapes particular on his feet since he was wearing sandals during the accident. Patient complains of pain redness to a wound on the left foot. No fevers. No drainage. No reported foreign body or foreign body sensation. Patient scheduled to see Dr. XXXX from Orthopedics tomorrow for further assessment of the foot injuries. patient is ambulatory.

Impression:

Puncture wound of left foot excluding toes with infection, initial encounter

Encounter for wound re-check
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The open wound category S91.- includes an instructional note stating "Code also any associated wound infection". I take this to mean that I should code S91.332A along with L08.9 (Local infection of the skin and subcutaneous tissue, unspecified).
S91.332A
L08.9

But I've seen from others on the forum that if the wound infection is due to trauma, I should instead code T79.8XXA (Other early complications of trauma)?
T79.8XXA

How would you code this scenario? Thanks. :cool:
 
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