Clean Up Your Ankle Wound Coding With These 3 Tips
Find the cause of the wound before you select a code. Checking the medical documentation of a patient’s encounter is especially important when you’re coding a wound care situation, because the type of wound, the cause, and the exact location of the wound all affect your potential code choices. Don’t waste time in the wrong part of your ICD-10-CM book: Use these tips to keep your ankle wound care coding on track. Tip 1: Focus on the Type of Wound First ICD-10-CM offers many codes for open wounds of the ankle. They include the following: Unspecified wounds: Don’t miss: Although ICD-10-CM offers unspecified codes, you should avoid them and always check the documentation for specific details, so you can report to the highest specificity. Lacerations: Puncture wounds: Open bites: Tip 2: Remember to Include These Complications A coding note for category S91- (Open wound of ankle, foot and toes) tells you to “code also any associated wound infection.” Therefore, you should always make sure that you code for any infection of the wound. Coding example: A patient presents to the office with a laceration of the right ankle. This is an initial encounter. There is no foreign body in the wound. The patient sustained the wound from a broken window. The wound is swollen, red, and painful, and has a yellow discharge from it. The podiatrist takes a culture of the laceration to determine possible staph infection. You should report S91.011A (Laceration without foreign body, right ankle, initial encounter) for the laceration, along with the proper code such as B95.8 (Unspecified staphylococcus as the cause of diseases classified elsewhere) for the staph infection. Important: The unspecified code, B95.8, is billable on your initial claim, says Jeri L Jordan, CPC, billing manager at Hampton Roads Foot and Ankle in Williamsburg, Virginia. However, for follow-up visits, you would use the results from the lab for a more specific code. Also, you should never report B95.8 as the primary diagnosis. You should also report W25.XXXA (Contact with sharp glass, initial encounter) as the external cause code. When using an external cause code, never report it as the primary diagnosis, Jordan explains. You may use more than one external cause code if needed, such as W18.02XA (Striking against glass with subsequent fall, initial encounter) if it happened with a subsequent fall. Tip 3: Consider These Questions As you can see from the above code descriptors, when you report open wounds of the ankle, you must know many details, such as whether the right or left ankle was affected. Take a look at the questions you should keep in mind when reporting open wounds of the ankle:
