A patient, with type 2 diabetes mellitus, presented for follow up of a previous traumatic laceration, which the patient reported had worsened. The provider documented diabetic ulceration secondary to laceration of the left ankle, and further described the ulcer as full thickness with breakdown of skin. Are two codes assigned, one for the laceration and one for the ulcer? Alternatively, should only the ulcer be coded? How should this diagnosis be reported?
Assign codes E11.622, Type 2 diabetes mellitus with other skin ulcer, L97.322, Non-pressure chronic ulcer of left ankle with fat layer exposed, and S91.012S, Laceration without foreign body, left ankle, sequela, for the diabetic full thickness ulceration with breakdown of skin secondary to the laceration of the left ankle.
In this case, the laceration has evolved to an ulceration. The ulcer is a different problem; requires different treatment; and would be classified as sequela of the laceration. Therefore, codes are assigned for the diabetic ulcer and the laceration, to fully capture the patient’s conditions.