2025 ICD-10-CM code W53

Contact with a rodent, including contact with saliva, feces, or urine.

Always use an additional code from another chapter (typically Chapter 19) to specify the nature of the injury sustained.Code W53 alone is insufficient.

Modifiers are not applicable to ICD-10 codes.

Medical necessity is established by the presence of a documented injury or illness resulting from the contact with a rodent.Documentation must support the clinical findings and the medical necessity of the treatment rendered.

The clinical responsibility depends on the type of injury and subsequent treatment.This could involve primary care physicians, emergency medicine physicians, infectious disease specialists, or surgeons, depending on the severity and nature of the injury.

IMPORTANT W53.0: Contact with mouse; W53.1: Contact with rat; More specific codes exist within W53 to indicate the type of rodent and the nature of the contact (e.g., W53.01: Bitten by mouse; W53.11: Bitten by rat).Additional codes from Chapter 19 (Injury, poisoning, and certain other consequences of external causes) are always required to describe the injury itself.

In simple words: This code is used when someone has come into contact with a rodent, such as a mouse or rat. This could mean being bitten, scratched, or even just touching the rodent or its droppings.A separate code will be used to describe the injury itself, like a bite wound or an infection.

This code classifies encounters resulting from contact with rodents, encompassing direct contact with the animal itself or indirect contact through its saliva, feces, or urine.It's crucial to note that W53 describes the circumstance of the injury, not the injury itself.Therefore, additional codes from other chapters (most often Chapter 19: Injury, poisoning, and certain other consequences of external causes) are needed to specify the nature of the injury sustained (e.g., bite, scratch, infection).This code is used secondarily to a code that specifies the injury.

Example 1: A patient presents to the emergency department after being bitten by a rat while working in a warehouse.The physician documents the bite wound, cleans and sutures the wound, and administers a tetanus shot.Codes W53.11 (Bitten by rat) and codes from Chapter 19 describing the wound would be used., A child is brought to the pediatrician’s office with a suspected rat-bite fever. The child had been playing in an area known to have rodents.W53 would be used along with codes from Chapter 19 reflecting the diagnosis and clinical findings., A patient presents to a clinic with symptoms consistent with hantavirus pulmonary syndrome after exposure to rodent droppings during home renovations. W53, along with the appropriate infectious disease code, would be utilized.

Complete documentation should include a detailed description of the encounter with the rodent (type of rodent, manner of contact, location of exposure), the nature and location of any injuries sustained (e.g., bite, scratch, abrasion, location and size), all relevant physical exam findings, treatment administered, and any diagnostic testing or procedures performed.Documentation must also support medical necessity for all services provided.

** Always ensure proper documentation to support the diagnosis and treatment.Use the most specific code possible within the W53 range to reflect the type of rodent and nature of contact.This code should never be used in isolation; it must always be accompanied by codes describing the injury sustained.

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