Blackhorse Posted Thu 12th of December, 2019 15:57:31 PM
72 year old male is here for an evaluation of a left posterior lower leg wound. It started after an Achilles surgery in May, 2018. He had a wound dehiscence and an infection. It became mostly healed by August, 2018. However he still notices some minimal drainage from a dry eschar that he has around the distal portion of the incision. The podiatrist who was taking care of him was recommending a tendon transfer surgery. He is here for another opinion. Exam: He has a wound, not completely healed, over the posterior heel with a dry eschar in place. There is minimal serous drainage. There is no deep wound noted. Doctor's Dx is "left posterior lower leg wound" and left achilles tendon insufficiency. A coder use S81.802A for the wound but I'm not sure if it's correct. What about T81.31XA?
SuperCoder Answered Fri 13th of December, 2019 06:20:54 AM
Thank you for your Question.
ICD 10 CM code S81.802A (Unspecified open wound, left lower leg, initial encounter) is appropriate when the physician documents only the open wound of leg. If the documentation supports that the wound is due to previous surgery or wound dehiscence or non-healing or complication by previous procedure then the ICD 10 CM code series T81.31XA is better choice of code. Please choose appropriate code as per the documentation provided by the physician.
Hope that helps!