tci ED Coding & Reimbursement Alert - 2004 Issue 12

Don't Jump the Gun With Wound Coding

Treatment doesn't always include explorationWhen a patient presents in the ED with a wound caused by a foreign object, don't assume you need a foreign-body removal (FBR), laceration, or exploration code, because sometimes the absent documentation says more than what's written. Solve this case study and see if you can navigate around these pitfalls. Physician's documentation: Presenting complaint: Nail in hand.  History of present illness: Otherwise healthy left-handed roofer shot himself in the right hand with a nail gun at work three hours ago. Nail is still in place at the base of the middle finger in the...

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