Home Health ICD-9/ICD-10 Alert
Simplify Complicated Wound Coding
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Question: We have had patients who were receiving care for trauma wounds that didn’t heal as expected. How do we know when wound become non-healing for coding purposes? And how do we code for it?
Answer: A complicated trauma wound is defined as one that has delayed healing, delayed treatment, the presence of a foreign body, or infection. But you can’t report a wound as non-healing unless the physician confirms the complication diagnosis. The Official ICD-9-CM Guidelines for Coding and Reporting require the physician to determine whether a complication exists and establish the cause and effect relationship between the care and the complication.
If a trauma wound is complicated, it usually only requires a change to the fourth digit. For example, 891.0 (Open wound of knee, leg [except thigh], and ankle; without mention of complication) describes a trauma wound to the leg (except thigh). Change the fourth digit to “1” for 891.1 ( ... complicated) to indicate that the trauma wound is complicated.
— New York Subscriber
Home Health ICD-9/ICD-10 Alert
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