History of Present Illness: 2 days ago, slid right calf along asphalt. Long abrasion on outer aspect of right calf and lower knee.
Skin Examination: Large area of abrasion on the right lateral calf with no discharge but with erythema extending out about 1 cm medially that is tender to palpation.
Assessment: Abrasion of the right leg.
Therapy: Wound was cleansed with sterile physiologic (normal) saline solution and sterile gauze. Border was drawn with permanent marker around edge of erythema. Dressing applied. After cleansing, mupirocin, silver sulfadiazine, and non-adherent dressing were applied. They were secured with soft roll and self-adherent wrap.
What International Classification of Diseases, 10th Revision, Clinical Modification and Current Procedural Terminology® codes would you assign for this service? Answers can be found in this month’s Online Exclusives!