OASIS Alert

Published on Fri Aug 06, 2010 PDF

Hint: If you get stumped, look to the origin of the wound for guidance.

Coding for any patient can present some twists and turns along the path to the correct code, but coding for patients with wounds can really throw you a curve. Cut out the following list of tips from Joan Usher with JLU Health Record Systems in Pembroke, Mass. Then post it somewhere your clinicians can easily get to when they need a refresher.

-- Treatments to wounds such as debridement and skin grafts don't change the wound itself.

-- Look back to the origin of the wound to guide your code selection.

-- While open wounds in the 800 series will earn case mix points under the Skin 1 category, surgical wounds don't pull case mix points by diagnosis alone. They may, however earn case mix points when combined with certain answers to other M items.

-- Surgical wounds with dehiscence, post op wound infections, non-healing, or that aren't clean, do pull points from the skin 1 category because they are complicated.

-- Ulcerations can be confusing. Look to origin of wound. The clinician may call a diabetic ulcer a "diabetic wound" but it is actually a manifestation of the disease process. The terminology in the clinician's description may not match the coding lingo. Always go back to the origin of the wound.

-- An ostomy reversal or take down is no longer an ostomy it becomes a surgical wound.