Cracking the Code

Superficial Injuries with Severe Injuries

There are several different types of injuries that people may sustain. In the medical coding world, there are superficial injuries (i.e. abrasions, contusions, bites, and blisters). However, there are more severe injuries (i.e. fractures, sprains, and lacerations) that may occur as well. When the provider’s documentation has both superficial and severe injuries reported, it is appropriate to ONLY report the more severe injury. Per ICD-10-CM Official Guidelines for Coding and Reporting FY 2022 Section I.C.19.b.1., “Superficial injuries such as abrasions or contusions are not coded when associated with more severe injuries of the same site.” Therefore, it is inaccurate for a coder to report both conditions as final diagnoses. It is imperative for coders to understand this guideline to submit a clean claim and uphold the coding guidance to the best of their abilities.

Q: A 18-year-old male presents to the ED with complaints of left ankle pain. The patient was playing basketball on the basketball court in his neighborhood and collided into another player. The patient sustained an abrasion and fracture of their left ankle.
A: S82.892A, Other fracture of left lower leg, initial encounter for closed fracture
Reference: References: ICD-10-CM Official Guidelines for Coding and Reporting FY 2022 Section I.C.19.b.1.
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