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wound care

  1. #1
    Question wound care
    Medical Coding Books
    I need some help with wound care. My podiatrist wants to bill 15430 for application of Oasis collagen wound matrix and I want to be sure his documentation supports this. Here's the report:

    The patient presents to _______ Wound Care Center for followup
    evaluation of midfoot ulceration, which we have been treating over
    the course of the past several months. The patient has sustained
    direct trauma to this area secondary to noncompliance and
    weightbearing following resection of the 4th and 5th metatarsals
    for treatment of osteomyelitis and abscess formation.

    Physical examination of the patient's lower extremity today
    reveals no ulceration at the level of the midfoot with complete
    resolution and healing at the surgical site. The previous area of
    anterior ankle ulceration has remained completely resolved.
    However, the patient now has a new ulcer at the plantar aspect of
    the heel, which is with multiple punctate satellite areas along
    the heel with depth of approximately 0.1 cm and diameter of
    approximately 1 x 1 cm, in series of 4-5 different lesions. The
    area appears to be erythematous secondary to irritation and
    pressure being placed on the plantar and posterior aspects of the
    heel. The patient has been donning her Posey boot; however, it
    does appear as if some pressure has been borne on the lower
    extremity in this area, which would be the cause for the recent
    new breakdown. The patient's lower extremity epidermis is very
    thin and fragile due to the past history of previous ulceration,
    which also lends itself for further breakdown and wound
    complication. The area appears to be without infection; however,
    there is a great deal of sloughing skin noted at the heel, part of
    which is partially adhered. There is some concern about localized
    debridement potentially causing further excoriation and wounds.
    Therefore, the patient will be referred for physical therapy and
    whirlpool treatment for aquatic debridement.

    1. Decubitus ulceration of the heel.
    2. Resolution of midfoot ulceration.

    Treatment today is:
    1. Referral for whirlpool debridement x5.
    2. Application of Oasis collagen wound matrix under sterile
    conditions following wound bed preparation via debridement
    with application of Adaptic, 4 x 4's, 4-inch roll bandage,
    and 4-inch Ace bandage.
    3. The patient is to remain completely nonweightbearing on the
    affected lower extremity.
    4. Patient will return to St. Mary's Wound Care Center in 1 week
    for further evaluation.

  2. Default
    Here are a couple of links I found in regards to coding the Oasis Wound Matrix, I hope this helps.

  3. #3
    15430 is the correct code for application of Oasis up to 100 sq cm. There is a few problems though with this documentation. The Oasis needs to be "affixed" , Oasis is usually affixed with steri-strips, however, here it looks like it is just stabilized with dressings. If it isn't affixed, it is considered a "wound dressing" and you would only be able to code the debridement,,, which has a problem too, as he doesn't state the depth, e.g. partial thickness, full thickness, subq,,,etc.
    Also will probably be denied with a pressure ulcer code. Usually used on venous insufficient and diabetic ulcers.

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