Home Health & Hospice Week

Your patient's surgical wound may be complicated, but coding for it doesn't have to be. Follow three simple steps to make sure you're accurately reporting all the care your agency provides.

1. Know when it's complicated. A complication is a problem that arises during the healing process of the initial surgical procedure which negatively impacts healing, says Judy Adams, president and CEO of Adams Home Care Consulting in Chapel Hill, N.C. For example, an infected surgical wound is considered complicated.

Tip: There's no time limit to coding a surgical wound as complicated, Adams says. Even if the complication arises some time after surgery, you can still code for the wound as complicated.

2. Find the right code. Look under "Complication" in the alphabetic index of your coding manual to begin your search, Adams says. Then verify the code in the tabular list, and follow the directions for any additional codes. There are many com plication codes for wounds of all types in chapter 17 at 996.xx (Complications peculiar to certain specified procedures), 997.6x (Amputation stump complication), 998.3x (Disruption of wound), and 998.5x (Postoperative infection) for postoperative wound complications, Adams points out. Also look to 998.83 (Non-healing surgical wound) and 997.xx (Complications affecting specified body systems, not elsewhere classified).

3. Don't turn to aftercare. Even though your agency is providing care post-surgery, you shouldn't use an aftercare V code when the surgical wound is complicated. The complication code trumps the aftercare V code in this case. Coding guidelines advise: "The aftercare V code should not be used if treatment is directed at a current, acute disease or injury. The diagnosis code is to be used in these cases."

However, you may occasionally find an exception to this rule. For example, if your agency is caring for an infected surgical wound which requires IV care, you would use the appropriate complication codes to report the wound, but you could still list V58.81 (Fitting and adjustment of vascular catheter) and V58.62 (Long-term [current] use of antibiotics).