How is a gunshot wound (GSW) to the head with entry and exit wounds coded?

A gunshot wound (GSW) to the head with both entry and exit wounds is coded as one injury because it represents a singular traumatic event affecting the body. In medical coding, the focus is typically on the overarching injury rather than the individual components unless there are distinct injuries that warrant separate coding.

In this case, while there are two points of injury (entry and exit), they are part of the same incident of trauma—the gunshot wound itself. Coding it as one injury simplifies the categorization and reflects the comprehensive nature of the trauma sustained. This practice is crucial in medical records and insurance claims, as it provides a clearer picture of the patient's condition and treatment needs without misrepresenting the severity or nature of the injury as separate entities.

Other options, such as coding it as two separate injuries, would inaccurately imply that the entry and exit points are independent incidents, which distorts the actual nature of the injury. Coding it merely as a potential fatal injury does not provide the complete information needed for treatment and documentation purposes, while classifying it as a defensive injury does not appropriately describe the circumstances of the wound or its causation.