Diagnosis for Open Wounds as a Result of Cancer Resection

November 17, 2016

Question:
What diagnosis code do we use when we are reconstructing a defect after the Moh’s surgeon, or someone else removed the cancer? When I try to crosswalk the ICD-9-CM open wound code I used to something in ICD-10-CM, it takes me to an S code which is strange because the open wound is not the result of an injury or trauma.

Answer:
Good question! Technically, you would not use a cancer diagnosis code since you are not treating cancer (the Moh’s surgeon treated the cancer by excising it). Your diagnosis codes, as the surgeon treating an open wound/resulting defect resulting from cancer resection are:

  1. Z48.1 Encounter for planned postprocedural wound closure, and
    2. Z42.8 Encounter for other plastic and reconstructive surgery following medical procedure, and
    3. Personal history of neoplasm code (e.g., skin Z85.82-, melanoma Z85.820). If the reconstruction occurs on the same day as the cancer removal, then the C code for malignant neoplasm can be substituted for the Z85.- code.

*This response is based on the best information available as of 11/17/16.

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