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This is a 68-year-old woman who had a history of a fall from a horse. The patient suffered multiple severe injuries which were treated surgically. Subsequently, the patient developed a hematoma (fluid collection) in her left thigh. The thigh area had become infected and developed cellulitis and abscess. The patient presented to the emergency department with complaints of fever and increasing pain. She was evaluated by the Orthopedic Trauma Service and later admitted for treatment of left thigh Morel-Lavallee lesion. An incision and drainage of soft tissue of the left thigh was performed. What is the correct code assignment for Morel-Lavallee lesion?
Assign code 924.00, Contusion of lower limb and of other and unspecified sites, Thigh, as the principal diagnosis. Assign code 682.6, Other cellulitis and abscess, Leg, except foot, as an additional diagnosis. Assign code 83.09, Other incision of soft tissue, for the procedure performed.
The Morel-Lavallee lesion (or closed internal degloving injury) is a significant soft-tissue injury associated with pelvic trauma in which the subcutaneous tissue is detached from the underlying fascia, generating a cavity filled with hematoma and liquefied fat.
Ask the Editor: Morel-Lavallee Lesion. AHA Coding Clinic for ICD-9-CM. 2009; Volume 26 Issue 1