Forum - Questions & Answers

Apr 21st, 2016 - churt31024 9

How to code

The patient has a 3/8th of an inch laceration noted to the facial chin area. The wound is noted to the subcu space. There is no foreign bodies noted to the wound space. The wound was clean with sterile water and hibiclens. The wound was anesthesized with 2 cc's of Lidocaine 1% soultion.

Was it sutured and were there different layers sutured? We need more info to help you. Did MD maybe suture subq tissue and then skin? Did he maybe use Dermabond? Or did he just anesthetize it, clean it, and steri-strip it? Do you need only I-10 dx and external cause codes for dx or also need CPT® code too? If you need external cause codes we also need to know how it was lacerated, where the pt was when the lac occurred, what he was doing if known (working for pay or volunteer working, or leisure or military duty).
Thanks.

child fell onto her chin while at school on a concrete surface. The child did not lose consciousness. The chin does have an open wound noted that is about 3/8th of an inch in length.The patient has a 3/8th of an inch laceration noted to the facial chin area. The wound is noted to the subcu space. There is no foreign bodies noted to the wound space. The wound was clean with sterile water and hibiclens. The wound was anesthesized with 2 cc's of Lidocaine 1% soultion. The wound was explored and no debris or foreign bodies noted. The patient's wound edges were approximated well with 3 (6-0) interrupted Prolene sutures. The wound was cleaned with sterile water, bandaid covering applied.