Health Information Management

Tip: Look for documented details of wound characteristics

APCs Insider, May 13, 2011

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Documentation for wounds should include specific details regarding the wound(s).Coders should look for documentation of the following:

  • Onset and duration: Knowing whether a wound is chronic or acute will help with treatment and outcome planning. It will also become more important after the switch to ICD-10-CM because coders will need additional detail to select the appropriate code.
  • Size: All wounds must be measured in centimeters for length (vertical), width (horizontal), and depth. Be sure the documentation indicates whether a wound has increased in size. If so, the provider may decide to reevaluate the wound, and the -documentation should reflect that.
  • Edema: The presence of edema can indicate under¬lying diseases and signify infection.
  • Peri-wound: Assessment must include inspection of the surrounding tissues.
  • Undermining: Undermining indicates the presence of a cavity under the peri-wound that is caused by shearing forces.
  • Tunneling: A tunnel is a tract or sinus extending into the underlying tissues from any point in the wound bed.
  • Exudate: Record the amount (e.g., none, minimal, moderate, copious), color (e.g., red, greenish-blue, yellow-clear), and odor.
  • Necrotic tissue: Document whether nonviable tissue is present and, if so, whether it is a particular color, such as black-brown (eschar) or yellow (slough).
  • Granulation tissue: The development of granulation tissue is the goal for full-thickness wounds. This area of the wound will look red and beefy and should increase in size with each wound reevaluation.

For ongoing wounds, look for documentation of improvement-or lack of improvement-in the wound over time. This is great information to bring to the attention of providers to ensure specifics are within the medical record.

The tip is adapted from “Dig into the details of wound care documentation” in the May issue of Briefings on APCs.

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