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MRA Thought of the Day – Those Pesky Open Wound Infections

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Scenario:

Cathie Wilde, RHIA, CCS, Vice President of Coding Services

Cathie Wilde, RHIA, CCS, Vice President of Coding Services

A patient was seen in the ER previously for a foot laceration occurring after stepping on glass while barefoot. The wound was sutured at the time. He now is admitted to the hospital three days later for treatment of foot cellulitis.

Question:

What is the Principal Diagnosis – complicated open wound or cellulitis?

Here are my thoughts…

  • Review of Coding Clinic references indicates a thorough assessment of infected wounds (or ulcers) and various case scenarios in the Second Quarter (1991, pp 5-7).
  • The sequencing of the diagnosis depends on the circumstances of the admission –If the patient is primarily admitted for treatment of the open wound, then complicated wound (892.1) would be assigned followed by the cellulitis code (682.7) to identify the specific complication. However, if the wound is trivial, does not require treatment, or was treated earlier and the main focus is treatment for the cellulitis (as in our example), then, the cellulitis is sequenced first followed by the complicated wound code.
  • Code for posttraumatic wound infection, NEC (958.3) is not assigned since we know the type of infection is cellulitis.
  • When does late effect of the laceration come into play? The patient’s wound (and cellulitis) is completely healed after three weeks, but now, the patient presents with foot pain which is worked up. A bone scan identifies osteomyelitis of the metatarsal, which the physician attributes to the original injury. Osteomyelitis (730.27) would be coded as the principal diagnosis followed by the late effect code (906.1).
  • What about E codes for external cause of injury? Coding Clinic (4Q 2009, pp 163-171) directs that the appropriate E code should be assigned for the initial encounter and not for the subsequent treatment. One exception to this is when acute fracture codes are still applicable the appropriate external cause of injury E code is still used. A late effect E code (E929.8) would be used in our osteomyelitis example above.

What are your thoughts?

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