What are the ICD-10 codes for a patient with lacerations on the left leg, bruising on the right hip, and a scrape on the left arm, with the last tetanus shot in 2008?

ICD-10 Coding for Patient with Lacerations, Bruising, and Scrapes

For a patient with lacerations on the left leg, bruising on the right hip, and a scrape on the left arm due to injury from rebar while running from dogs, the appropriate ICD-10 codes are S81.819A (Laceration of unspecified part of left lower leg, initial encounter), S70.01XA (Contusion of right hip, initial encounter), and S40.819A (Abrasion of left shoulder and upper arm, initial encounter).

Primary Injury Assessment and Coding

• The patient presents with multiple injuries from running into rebar while fleeing from dogs 1
• The main injuries include:
  • Lacerations on the left leg
  • Bruising on the right hip without pain
  • Scrape (abrasion) on the left arm

Laceration Coding

• For lacerations on the left leg, the appropriate ICD-10 code is S81.819A (Laceration of unspecified part of left lower leg, initial encounter) 1, 2
• This code is used because:
  • The injury is specifically described as a laceration
  • The location is the left leg
  • This is the initial encounter for the injury

Contusion Coding

• For the bruising on the right hip, the appropriate ICD-10 code is S70.01XA (Contusion of right hip, initial encounter) 1
• This code is used because:
  • The injury is described as bruising (contusion)
  • The location is specifically the right hip
  • This is the initial encounter for the injury

Abrasion Coding

• For the scrape on the left arm, the appropriate ICD-10 code is S40.819A (Abrasion of left shoulder and upper arm, initial encounter) 1
• This code is used because:
  • The injury is described as a scrape (abrasion)
  • The location is the left arm
  • This is the initial encounter for the injury

Tetanus Prophylaxis Considerations

• The patient's last tetanus vaccination was in 2008, which is more than 5 years ago 1, 3
• For patients with tetanus-prone injuries (including lacerations) who have not received a tetanus booster in the past 5 years, tetanus prophylaxis is recommended 1, 3
• The CDC recommends that adult patients who cannot confirm receipt of a tetanus booster during the preceding 5 years should be vaccinated with Tdap (or Td if Tdap is unavailable) 1
• Appropriate wound care and debridement are critical components of tetanus prevention 1, 4

External Cause Coding

• An external cause code should also be assigned to identify how the injury occurred:
  • W22.8XXA (Striking against or struck by other objects, initial encounter) for the injury from rebar 1
  • W54.0XXA (Bitten by dog) or W54.8XXA (Other contact with dog) can be added to indicate the circumstance of fleeing from dogs 1

Documentation Tips

• Ensure documentation includes:

  • Specific anatomical locations of each injury
  • Detailed wound characteristics (size, depth, contamination)
  • Tetanus immunization status and any prophylaxis provided
  • Treatment provided for each injury
  • Follow-up instructions 1, 2

• Minor injuries like these may still require careful assessment as even superficial wounds can lead to complications if not properly managed 5