Home Health ICD-9/ICD-10 Alert

Aftercare doesn't always need to be listed as the principal diagnosis.

When it comes to surgical wound coding there are three directions you can take. Do you know how to decide which is most appropriate for your patient?

Factors that go into determining how to code a surgical wound include whether to list an aftercare code, whether there are complications and whether you should list the surgical wound as a secondary code, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates in Denton, TX. To help guide your choices, she lists the following three ways to code surgical wounds precisely:

1. List an aftercare code when the condition is resolving;

2. List a complication code if surgical wound complications are present; or

3. List the aftercare code as secondary if the patient had surgery but the focus of care is either the reason for the surgery or some other condition.

List an aftercare code for wound care only if there is no complication to the wound and your agency will be providing normal and routine aftercare for the surgical wound, says Judy Adams, RN, BSN, HCS-D, with LarsonAllen in Charlotte, NC.

To select the correct aftercare code, check to be sure the reason for surgery falls within the range of codes that are listed for each of the aftercare codes -- V58.4x (Other aftercare following surgery) and V58.7x (Aftercare following surgery to specified body systems, not elsewhere classified), Adams says.

Code V58.42 (Aftercare following surgery for neoplasm) for conditions classifiable to 140-239, V58.43 (Aftercare following surgery for injury and trauma) for conditions classifiable to 800-999, [except aftercare for traumatic fractures which are excluded from this code and reported instead with codes from V54.10-V54.19, (Aftercare for healing traumatic fracture)] and V58.44 (Aftercare following organ transplant) are more specific than the aftercare for surgery of specific body systems, V58.7x codes, Adams says.

If a condition responsible for surgery does not fit into one of the specific designated surgical aftercare codes, then you can report it with V58.49 (Other specified aftercare following surgery), Adams says.

Coding example: Your patient has fibrocystic disease of the breast and has had surgery. Because this isn't a neoplasm, injury or transplant, you would look to the V58.7 codes, Selman-Holman says. In this case, V58.76 (Aftercare following surgery of the genitourinary system, NEC) is the right aftercare code. The notes next to V58.76 indicate that this is the right aftercare code for conditions classifiable to 580-629, and the reason for your patient's surgery was 610.1 (Dif-fuse cystic mastopathy).

To find the right code for a complicated wound, look under "complications" in the alphabetic index and then confirm the code in the tabular index, Adams says. There are a number of codes dedicated to specific complications in chapter 17 in categories 996 (Complications peculiar to certain specified procedures), 997.0x (Nervous system complications) and 998 (Other complications of procedures, not elsewhere classified).

Use the most specific code available to describe the actual surgical complication, and avoid using an aftercare code for complicated surgical wounds because the presence of a complication is not routine aftercare, says Adams.

Coding example: Your patient has an implanted port infected with Staphylococcus aureus that is resistant to penicillin and bacitracin. For this patient, you would list the following codes, Adams says:

• M0230: 999.31 (Infection of a central line);

• M0240: 041.11 (Staphylococcus aureus);

• M0240: V09.0 (Infection with microorganisms resistant to penicillins);

• M0240: V09.81 (Infection with microorganisms resistant to multiple drugs).

Your patients' surgical wounds, however, won't always be the focus of care. So in some cases, you'll need to list an aftercare code as secondary, Selman-Holman says.

Coding example: Your patient had her gall bladder removed. While in the hospital, she caught an upper respiratory infection which exacerbated her chronic bronchitis and her hypertension. She has some small incisions from her gall bladder surgery, but the focus of care is the acute infection and the hypertension. Use the following codes for this patient, Selman-Holman says:

• 491.22 (Obstructive
Chronic bronchitis; with
acute bronchitis)

• 401.9 (Essential hypertension; unspecified)

• V58.75 (Aftercare 575.0 (Acute cholecysti following surgery of tis) the teeth, oralcavity and digestive system, NEC).

Don't miss: Although the cholecystitis is resolved because the patient no longer has her gall bladder (due to the surgery), listing 575.0 in M0246 makes you eligible for case mix points as well as risk adjustment, Selman-Holman says. But don't code for the cholecystitis in M0240 because the condition no longer exists, she says.