Ask the expert: Coding a wound due to a cat bite
HIM Connection, July 29, 2008
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Q: How should I code the following scenario?
History: A 52-year-old female presents as a new patient with a complaint that her cat bit her several days ago while she was trying to coax it out of a corner. The patient has a history of hypertension and hyperlipidemia. The cat bit the second through fourth fingers on her left hand. There was also a small bite on the right hand. Her fingers are swollen. The cat ran away and has not been caught. It has not had its rabies vaccination but has never been outdoors.
Exam: The patient’s vitals are stable, with a temperature of 98.5 degrees, a pulse of 110, and blood pressure controlled at 120/80. In general, the patient is pleasant, alert, and in no distress. Her index and long fingers on the left hand are swollen. There are tiny puncture marks over the dorsum of the fingers and palm. She has full range of motion. There is some bruising and discoloration.
A: If the wound has not yet been treated, refer to the following in the 2008 ICD-9-CM Manual index:
Wound, open,
finger(s) (nail) (subungual) 883.0with tendon involvement - 883.2complicated—883.1 (Complicated means delayed healing, delayed treatment, foreign body or infection. Use additional code to identify infection.)
However, in this case, without further information, the correct codes to report at 883.0 (Open wound of finger, without mention of complication), E906.3 (Bite of other animal except arthropod), and E849.0 (Place of occurrence, home).
Editor’s note: This Q&A was excerpted from the July issue of Briefings on Coding Compliance Strategies. For more information, visit www.hcpro.com/content/213844.cfm.
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