OASIS Alert

Published on Wed Sep 24, 2008 PDF

Can you conquer these surgical wound coding conundrums?

Surgical wound coding can be complicated at best and confusing at worst.

You can keep your wound coding know-how up to snuff with sample scenarios that help you stay on top of the game.

Here are a few examples:

Scenario #1: A physician aspirates your patient's joint. The procedure leaves behind a small puncture area. Would you report this area as a surgical wound?

Solution: If a needle was inserted simply to aspirate fluid, but was then removed without leaving a drain or other object in its place, the site should not be reported as a surgical wound, according to the Centers for Medicare & Medicaid Services in the April 2008 set of OASIS questions and answers posted on the OASIS Certificate & Competency Board's Web site.

Scenario #2: Your patient suffers from constant joint swelling and pain. A physician uses a drain to fully aspirate the area. Should the wound that drain leaves behind be reported as a surgical wound?

Solution: When a surgical procedure creates a wound in which a drain is placed (e.g., an incision or stab wound), the presence of the drain (or drain wound site until healed) should be reported as a surgical wound, OCCB reports.

Scenario #3: A physician uses arth-roscopy to fully diagnose and treat your patient's chronic joint pain. Should the site of the procedure be reported as a surgical wound?

Solution: If a physician uses arthro-scopy to perform a surgical procedure, the arthrocentesis site would be considered a surgical wound until it heals and becomes a scar/lesion.

Next step: You should develop a list of sample scenarios that best fit your home health workers' areas of confusion or inconsistency. That way, you can provide practical training while reinforcing your agency's rules.