The HPI says "About 3 weeks ago, patient fell and hit left leg, causing a wound which has failed to heal despite several rounds of antibiotics and local wound care. The wound is getting larger and the patient is having more pain."

Exam says "the patient has a wound on the left anterior shin with exposed tendon. left foot is warm and well perfused. Palpable left femoral pulse. Nonpalpable popliteal pulse and nonpalpable pedal pulses."

Patient is elderly; is a current tobacco user, and has chronic lower extremity edema. Patient has not been seen previously by this medical group.

I’ll probably use S89.92X_, but is an A or an S more accurate? The wound has been seen and treated, just not by this practice, and after 3 weeks it should be healing, not increasing in size.

In this particular case, the provider gave information about the etiology, duration, depth, and location of the wound. Usually the reports from this office just say that there’s a non-healing wound on the left (or right) lower extremity. Is it best to just use L97.819/L97.829 in that case?