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Can someone please tell me the proper codes for a non-healing surgical wound of the abdomen? There is active treatment, so is it T8189XA? What other codes should I code? open wound of abdomen? what are the injury codes?
I think a better code would be maybe T81.31xA. For the disruption of surgical wound. However without the actual note it is just a guess. No you do not code a traumatic injury code just the complication code.
Can someone please tell me the proper codes for a non-healing surgical wound of the abdomen? There is active treatment, so is it T8189XA? What other codes should I code? open wound of abdomen? what are the injury codes?
This may be too late for you, but I ran into the same dilemma today. My best guess is to code T81.89XS and S31.109D (the patient has an open wound due to a surgical procedure that is slow to heal but is NOT dehisced or infected, so it is an complication of surgery-sequela/open wound in the healing status)
You do not use the trauma injury codes such as the S31.109D unless this had been a trauma wound prior to surgery. You would not use the trauma vide with the complication code and there is no sequela documented. If this were a surgical procedure for something other than trauma and the would had been closed but was not healing as fast as expected but with no documented actual complication then it is surgical aftercare. If there is a document reason for non healing then you would use the complication of surgery code and you would use the A character as this would be active treatment for a complication. I use the dehiscence as an example of what could be a surgical complication. You would use other complication only if the provider documented a complication that could not be coded with any other code.