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.