RE: re-open of craniotomy

Pt. had a skull fracture of some sort with a craniotomy. The area has re-opened. No mention of any complication just routine dressing change per SN. Wound is very small. H&P reads S02.91XS. I am guessing I should use this code with 7th "D" but how do I capture the wound? Seems like it should be a complication but no mention of one.

Thank you!
Lisa
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Comments

  • Hi Lisa
    If the wound is dehisced superficially per the nurses documentation, you can use T8131xd and the fracture code. If you don't have the reason for dehiscence.
  • edited April 2017
    I think this is exactly what I was looking for----thank you sooooo much :)
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