Open wound of chin. Open wound of face. Open wound of forehead. Open wound of jaw. ICD-10-CM S01.80XA is grouped within Diagnostic Related Group (s) (MS-DRG v38.0): 604 Trauma to the skin, subcutaneous tissue and breast with mcc. 605 Trauma to the skin, subcutaneous tissue and breast without mcc.
Open wound of forehead Open wound of jaw ICD-10-CM S01.80XA is grouped within Diagnostic Related Group (s) (MS-DRG v38.0): 604 Trauma to the skin, subcutaneous tissue and breast with mcc
Many codes in Chapter 19 of ICD-10-CM (Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88)) require a 7th character to identify the episode of care: initial, subsequent, or sequela.
Then, Steri-Strips were applied to wound. Based on this documentation, the correct ICD-10-CM code is S81.812A Laceration without foreign body, right lower leg, initial encounter. HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old male. He states that he was breaking up a fight between the dogs and was bitten on his hands.
The types of open wounds classified in ICD-10-CM are laceration without foreign body, laceration with foreign body, puncture wound without foreign body, puncture wound with foreign body, open bite, and unspecified open wound. For instance, S81. 812A Laceration without foreign body, right lower leg, initial encounter.
Coding of a sequela requires reporting of the condition or nature of the sequela sequenced first, followed by the sequela (7th character "S") code. Examples of sequela (7th character "S") diagnosis codes included in this policy: M48. 40XS (Fatigue fracture of vertebra, site unspecified, sequela of fracture)
Example 3: A sequela character (“S”) is applied for complications or conditions that arise as a direct result of a condition or injury (in ICD-9, these were known as “late effects”). Examples may include joint contracture after a tendon injury, hemiplegia after a stroke or scar formation following a burn.
To code skin tears, begin in the alphabetic index under “INJURY, SUPERFICIAL,” and iden- tify the site of the injury. For example, if the patient has a skin tear because he or she has hit a leg on a wheelchair, look up Injury, Su- perficial, leg, which takes you to S80. 92-.
D (subsequent encounter) describes any encounter after the active phase of treatment, when the patient is receiving routine care for the injury during the period of healing or recovery. S (sequela) indicates a complication or condition that arises as a direct result of an injury.
Some conditions may be diagnosed retrospectively from their sequelae. An example is pleurisy. Other examples of sequelae include those following neurological injury; including aphasia, ataxia, hemi- and quadriplegia, and any number of other changes that may be caused by neurological trauma.
However, it is important to note that with a sequela, the acute phase of an illness or injury has resolved or healed, and the sequela is left. Conversely, a complication is a condition that occurs as a result of treatment, or a condition that interrupts the healing process from an acute illness or injury.
Injury Guidelines For Sequela The code that describes the sequela is reported first, followed by the code for the specific injury with a seventh character of S to identify the condition as a sequela of the injury.
Sequela (Late Effects) Coding of sequela generally requires two codes sequenced in the following order: The condition or nature of the sequela is sequenced first. The sequela code is sequenced second.
Burn Wound Burn wounds can be classified based on the extent of the injury: First-degree burns affect only the epidermis and may cause redness and pain. Second-degree burns affect the epidermis and the dermis and may cause blisters. Third-degree burns reach into the fatty layer under the skin and may destroy nerves.
Open wound types include abrasions, excoriation, skin tears, avulsions, lacerations and punctures, according to our Skin and Wound Management course workbook. Traumatic open wounds involve a disruption in the integrity of the skin and underlying tissues caused by mechanical forces.
A skin tear is a specific type of laceration that most often affects older adults, in which friction alone or friction plus shear separates skin layers.
The ‘S’ is added only to the injury code, not the sequela code. The seventh character ‘S’ identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code.”.
There is no time limit on when a sequela code can be used. The residual effect may be present early or may occur months or years later. Two codes are generally required: one describing the nature of the sequela and one for the sequela. The code for the acute phase of the illness or injury is never reported with a code for the late effect.
Main term entries in the ICD-10-CM index for open wounds can be either the type of wound (e.g., puncture), or the term wound, open. Using either term will allow the coder to find the correct type of wound and anatomical location by using the indented subterms. For example, if you look up puncture wound of the abdomen in the index using the main term Wound, open and then go to the subterms Abdomen, wall, puncture, an instructional note will guide you to “see” Puncture, abdomen, wall.#N#Example 1:
Type of wound — Open wounds include: Abrasions: Shallow, irregular wounds of the upper layers of skin. Caused by skin brushing with either a rough surface or a smooth surface at high speed. Usually present with minor to no bleeding, with some pain that subsides shortly after initial injury.
Lacerations are generally caused by trauma or contact with an object. Incisions: Typically the result of a sharp object such as a scalpel, knife, or scissors.
Penetrating wounds can be life threatening, causing serious injury, especially if involving vital organs, major blood vessels, or nerves. Gunshot wounds: These are considered to be penetrating wounds that are exclusively caused by bullets from firearms (guns, rifles, etc.).
Depending on the depth and site of the wound, an incision can be life threatening, especially if it involves vital organs, major blood vessels, or nerves. Punctures: Small, rounded wounds that result from needles, nails, teeth (bites), or other tapered objects.
The puncture wounds on the patient’s hands are not gaping and I think the risks outweigh the benefits of any type of suture closure. The wounds are quite small and I think suturing them would likely increase their risk of infection. IMPRESSION: Dog bite.
In other words, sequela are the late effects of an injury. Perhaps the most common sequela is pain. Many patients receive treatment long after an injury has healed as a result of pain. Some patients might never have been treated for the injury at all.
ICD-10-CM defines subsequent encounters as “encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase. Examples of subsequent care are: cast change or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following injury treatment.”#N#A seventh character “D” is appropriate during the recovery phase, no matter how many times he has seen the provider for this problem, previously.#N#Note that ICD-10-CM guidelines do not definitively establish when “active treatment” becomes “routine care.” Active treatment occurs when the provider sees the patient and develops a plan of care. When the patient is following the plan, that is subsequent. If the provider needs to adjust the plan of care—for example, if the patient has a setback or must returns to the OR—the care becomes active, again.
ICD-10-CM says the seventh character S is “for use for complications or conditions that arise as a direct result of an injury, such as scar formation after a burn. The scars are sequelae of the burn.” In other words, sequela are the late effects of an injury.#N#Perhaps the most common sequela is pain. Many patients receive treatment long after an injury has healed as a result of pain. Some patients might never have been treated for the injury at all. As time passes, the pain becomes intolerable and the patient seeks a pain remedy.#N#A late effect can occur only after the acute phase of the injury or illness has passed; therefore, you cannot report a code for the acute illness and a code for the late effect at the same encounter, for the same patient. The only exception occurs if both conditions exist (for example, the patient has a current cerebrovascular condition and deficits from an old cerebrovascular condition).#N#When reporting sequela (e), you usually will need to report two codes. The first describes the condition or nature of the sequela (e) and second the second describes the sequela (e) or “late effect.” For example, you may report M81.8 Other osteoporosis without current pathological fracture with E64.8 Sequelae of other nutritional deficiencies (calcium deficiency).#N#If a late effect code describes all of the relevant details, you should report that one code, only (e.g., I69.191 Dysphagia following nontraumatic intracerebral hemorrhage ).#N#For example: A patient suffers a low back injury that heals on its own. The patient isn’t seeking intervention for the initial injury, but for the pain that persists long after. The chronic pain is sequela of the injury. Such a visit may be reported as G89.21 Chronic pain due to trauma and S39.002S Unspecified injury of muscle, fascia and tendon of lower back, sequela.
The patient isn’t seeking intervention for the initial injury, but for the pain that persists long after. The chronic pain is sequela of the injury.