Wiki Large open surgical wounds

[dkgrabner@comcast.net]

I work in a skilled nursing facility and recently we have gotten a few post surgical admits that have large wounds left after their surgeries. These are not wounds caused by external trauma but left open to heal post surgical wounds. The most recent we had a resident that had abdominal surgery to remove a foreign object and the only closed part of the surgical opening and left the skin un-sutured an open. So my question is - how would I code(or would I even code) a post surgical wound like this.

Thank you for your advice!

Desiree
Medical Records Director
RHIT
CIC in training

 

[SharonCollachi]

If there is no complication, just left open, then you just code the Aftercare.

 

[dkgrabner@comcast.net]

Thank you! That is what I have been doing but some of the nurses here have been making me doubt my sanity.