Health Information Management

Follow these nine tips to capture inpatient wound care correctly

JustCoding News: Inpatient, October 10, 2012

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Inpatient!

By Lisa A. Eramo

 
Provider documentation of inpatient wound care services may be confusing at best and completely lacking at worst. Coders end up trying to decipher exactly what procedure the provider performed. Consider the following tips to help sort through wound care coding conundrums and ensure compliance.
 
Tip #1: Ensure diagnosic specificity. Before coders can report wound care services, they must ensure that providers have documented a diagnosis to justify those services, says Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, an AHIMA-approved ICD-10-CM/PCS trainer who has more than 30 years of experience in the HIM profession.
 
Patients who benefit from wound care may have active wounds (e.g., burns, abrasions, lacerations, punctures, or insect bites) or chronic wounds (e.g., pressure ulcers, venous ulcers, diabetic ulcers, or non-healing surgical wounds). The latter often require ongoing wound care treatment, says Bryant.
 
For example, patients with diabetes may have one of the following two types of diabetic ulcers:
  • Neuropathic ulcers: Patients with diabetic autonomic neuropathy (i.e., a nerve disorder and complication of diabetes in which a patient can’t feel irritation or pain) develop these types of ulcers. “Because [patients] can’t feel that an area of skin is being irritated, it can get to such a point that it totally breaks down,” says Robert S. Gold, MD, founder and CEO of DCBA, Inc., in Atlanta, Ga. “If it gets deep enough and gets infected, it can lead to inflammation deep into the skin and subcutaneous tissue and can go as far down as the bone and cause osteomyelitis.” These ulcers develop on chronic pressure points; however, they aren’t considered pressure ulcers, he adds.
  • Microvascular ulceration and necrosis: These ulcers occur when there is skin loss due to a lack of small blood vessel supply. Diabetes causes microvascular narrowing, which ultimately results in the death of skin tissue, Gold explains.
 
Not all patients with diabetes have diabetic ulcers, says Bryant. These patients may also have ulcers due to other conditions, such as nondiabetic peripheral neuropathy or peripheral vascular disease, she adds.
 
Venous stasis ulcers are shallow wounds that occur when deep veins are obstructed or when a patient has increased right heart pressure. These ulcers commonly occur in patients who are obese as well as those who have chronic obstructive pulmonary disease (COPD) or deep vein thrombosis, Gold explains. 
 
Constant pressure on the skin usually over a boney prominence causes pressure ulcers. They often occur on the heel, sacrum, scapular area, elbows, knees, and ankles. “These [ulcers] generally relate to people who can’t move over a period of time but who do have sensation or who may have autonomic neuropathy not due to diabetes,” says Gold.
 
Tip #2: Look beyond the procedure title. Once the provider has documented a diagnosis, determine what treatment was rendered. Coders shouldn’t ever rely solely on the procedure title when coding wound care or any other procedure, says Bryant. Always read the narrative description of the procedure before assigning a code for that procedure, she adds.
 
Treatment notes should ideally be a goldmine of information for coders, says Bryant. These notes should include:
  • Indications and impressions
  • Any changes in the condition of the wound
  • Any interventions performed to treat the wound as well as the outcome of those procedures pre- and post-procedural details related to the wound
  • Ongoing treatment plans
  • Next steps
 In addition, the notes should include a whole slew of details related to the wound itself, such as:
  • Dimensions--length, width, and depth documented in this order
  • Presence of any undermining or tunneling
  • Description of the wound base, including the presence of any granulation, necrotic tissue, eschar, slough, or epithelial tissue
  • Drainage, including the amount (e.g., small, medium, or heavy) and color/consistency (e.g., serous, serosanguineous, purulent, or other)
  • Wound edges
  • Presence of absence of any odor
  • Color of the wound
  • Pain associated with the wound
“You may already have some of this built into your electronic documentation tool if you have an EMR,” she says. “You may also have a sheet that has boxes. If you have narrative information only, you need to make sure that these elements are being obtained and written in the record.”
 
Tip #3: Use caution when reporting excisional debridement. When providers perform excisional debridement, which is one—but not the only—method of wound treatment, they excise devitalized tissue (e.g., burns, tissue that’s mangled as a result of trauma, or tissue affected by toxic epidermal necrolysis), necrotic tissue (e.g., gangrenous tissue), or slough, Gold explains. Providers may perform excisional debridement in the surgical suite, in the ER, or at the patient’s bedside.
 
Excisional debridement is specifically limited to skin and subcutaneous tissue and no level deeper than that (ICD-9-CM code 86.22). From a coding standpoint, excision debridement is challenging because documentation isn’t always clear, says Bryant. She says coders should look for these terms or phrases before considering code 86.22:
  • Surgical removal or cutting away of devitalized tissue, necrosis, slough down to healthy tissue that can heal
  • Extensive and aggressive removal of tissue with or without general anesthesia
  • Removal of dead or necrotic tissue or foreign material from and around a wound to expose healthy tissue using a sterile scalpel, scissors, or both
In contrast, non-excisional debridement (ICD-9-CM code 86.28) involves flushing, brushing, and washing of the burn, wound, or infection. As with excisional debridement, non-excisional debridement may also involve the removal of devitalized tissue, necrosis, or slough. It may also include minor removal of loose fragments via scissors. However, unlike excisional debridement, non-excisional debridement is non-operative in nature. 
 
Some providers may refer to a debridement procedure using scissors as selective debridement, says Gold. This is not the same as excisional debridement, he adds.
 
“You have to be careful when you’re reading through documentation. Look at the instrumentation that’s being used and the technique that’s being applied,” says Bryant.
 
Tip #4: Don’t make assumptions about instruments used during a procedure. Just because a provider documents that he or she used a sharp instrument doesn’t mean that he or she performed excisional debridement. “When doctors or nurses or therapists perform wound care with sharp instruments, you have to consider whether it indeed meets the intent of 86.22,” says Gold. “You have to ensure that the right code is used because it’s going to have perhaps different effects on hospital reimbursement.”
 
Bryant agrees. “I know the word sharp sometimes gets used by clinicians. Although that terminology typically reflects CPT®, we don’t usually find it in ICD-9 coding terminology,” she says.
 
Providers may also use scalpels, scissors, curette, or cutting-type tweezers to perform debridement, says Bryant. However, even scissors aren’t always indicative of excisional debridement. For instance, providers may use scissors to cut away loose fragments, which isn’t considered excisional debridement. Bryant says coders should verify how and why the provider used the scissors—was it truly to perform excisional debridement?
 
Likewise, even when providers use a scalpel or blade, coders can’t assume the provider performed an excisional debridement, says Bryant. They must review the procedure note before assigning a code.
 
Tip #5: Know other types of wound care treatment options. Debridement is one of many types of wound care treatments. Others include:
  • Topical wound care
  • Off-loading (i.e., preventing, reducing, or eliminating mechanical insults to skin and underlying tissue)
  • Heel protection (i.e., the application of a protective device or support to avoid contact or friction),
  • Infection control (i.e., wound dressing, diet, hygiene, and medication)
Coders sometimes incorrectly default to code 86.22 rather than report a more appropriate code simply because they don’t focus on the intent of the procedure or interpret the type of excision correctly, says Bryant.
 
Don’t overlook these procedure codes that may be more applicable:
  • 54.3, excision or destruction of lesion or tissue of abdominal wall or umbilicus
  • 77.60-77.69, local excision of lesion or tissue of bone
  • 83.45, other myectomy
  • 82.36, other myectomy of hand
  • 79.60-79.69, debridement of open fracture site
 
Tip #6: Don’t assign a code for vacuum-assisted closure (VAC). During a VAC, a provider applies controlled localized negative pressure to the wound and removes interstitial fluid and infectious materials by compressing the dressing. When a provider performs VAC, coders should only assign the appropriate ICD-9-CM code for the specific debridement performed. Refer to Coding Clinic, third quarter 2006, p. 17, for more information about VAC.
 
Tip #7: Determine whether the wound care is integral to another procedure. If it is, coders can’t code it separately, says Bryant.
 
For example, coders can’t code excisional debridement in addition to a graft when a provider performs the debridement to prepare a site to receive a skin graft during the same encounter, says Gold. Coders also can’t code excisional debridement in addition to a primary closure of a laceration or open fracture, he adds.
 
“Likewise, when you’re preparing a site for a flap closure of an abscess, the excisional debridement is part of the flap closure, and you don’t [code] it,” says Gold.
 
Tip #8: Know how to code debridement of multiple layers. When a provider debrides multiple layers of the same site, assign a code only for the deepest layer debrided, says Bryant. Don’t assign two or more codes when the debridement extends past the skin and subcutaneous tissue into the muscle or bone.
 
Tip 9: Communicate with providers. Coders need to tell providers what information is necessary to assign a complete and accurate code, says Gold. Coders can and should also advocate for more thorough documentation in general. He says providers are often better at documenting wounds located on a patient’s front side, and they need to be reminded to document those located on the patient’s backside or extremities as well. “It becomes really important to fulfill the requirements of medical necessity and [provide] a good picture of what’s wrong with the patient to get a diagnosis,” he says.
 
Educate providers about what they must document relative to excisional debridement in particular, says Bryant. This includes educating nurses, therapists, physician assistants, and physicians. According to Coding Clinic, second quarter 2000, p. 9, any of these providers may perform excisional debridement. Reiterate the documentation must include:
  • Level of debridement
  • Description of the wound (before and after)
  • Instrument used
  • Pain control
  • Response to treatment
  • ·Bleeding, hemostasis achieved
  • Any dressings or treatments
“Often, [providers are] not taught what’s needed for accurate and compliant coding in this area,” she says.
 
It’s also not too early to start talking with providers about ICD-10. Consider the following details that providers must document for pressure ulcers:
  • Precise location (laterality as well as level of the back).
  • Stage or tissues involved. In ICD-10, the involved tissues that providers document each correspond to a stage (e.g., skin corresponds with stage 1 and involving muscle corresponds with stage 3). “This is a benefit to clinicians because now, they don’t necessarily have to memorize how to stage a pressure ulcer,” says Gold. “They just have to tell you the part of the body that’s involved with the ulcer.”
 
Providers must document the following for all other types of ulcers:
  • Cause (e.g., arterial ulcer or venous ulcer)
  • Precise location (laterality as well as level of the back)
  • Depth of tissue actually involved
 
Editor’s note: The contact in this article was originally presented during HCPro’s audio conference Inpatient Wound Care Coding: Clinical Information and Documentation Strategies. Eramo is a freelance writer and editor in Cranston, RI who specializes in healthcare regulatory topics, health information management, and medical coding. You may reach her at leramo@hotmail.com.



Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Inpatient!

    The HIM Director's Handbook, Second Ed.
  • The HIM Director's Handbook, Second Ed.

    This second edition is an updated version of the earlier best seller and details everything you need to know to direct your...

  • The HIM Director's Guide to ICD-10

    ICD-10 is the biggest change for the HIM industry since the implementation of DRGs in the 1980s. HIM directors must take...

  • ICD-10 Trainer

    ICD-10 Trainer provides the latest news and updates related to ICD-10 regulations, and tips from HCPro experts and faculty...

  • Coding and You

    Coding and You is written specifically to help non-coders; medical assistants, lab technicians, compliance professionals...

  • Acute and Chronic Renal Failure Coding:

    Our experts address new AKIN criteria, acute vs. chronic kidney disease, and other clinical aspects of renal failure and...

Most Popular