Home Health ICD-9/ICD-10 Alert

You might be able to see down to the patient's bone, but you can't assume you have a trauma wound.

Wound care coding has many nuances. Take our experts' advice to ensure your diagnosis code choice most accurately represents the care you provide.

When coding for a skin ulcer, you'll look to the 707.xx (Chronic ulcer of skin) category. If the ulcer you're reporting is a pressure ulcer, you'll use the fourth digit "0" (Pressure ulcer). For non- ressure ulcers, you'll use fourth digit "1" (Ulcer of lower limbs, except pressure ulcer).

Tip: When you're using a 707.0x code to report a pressure ulcer, if the ulcer is the focus of your care, you can list this code in M1020a as the principal diagnosis, says Trish Twombly, RN, BSN, HCS-D, CHCE, director of coding with Foundation Management Services in Denton, Texas.

Caveat: If you're coding for a stasis, arterial, diabetic, or other ulcer that's not a pressure ulcer, it's not appropriate to list the ulcer code in M1020a -- even if the ulcer is the primary reason for home care, Twombly says. Instead, you should list the reason for the patient's ulcer in M1020a.

Coding example: Your agency is providing wound care for a patient's diabetic foot ulcer. You would list the following codes:

• M1020a: 250.8x (Diabetes with other specified manifestations)

• M1022b: 707.14 (Ulcer of heel and midfoot).

The official coding guidelines released October 1, 2009 contained new pressure ulcer guidelines. Chapter 12a stated that patients admitted with pressure ulcers documented as healed should not be assigned a code.

Prior to this instruction, home care coders assigned a code for closed stage III and IV pressure ulcers because these patients were at a greater risk for recurrent skin breakdown, which required continued monitoring, Twombly says.

Now, thanks to further clarification from the National Pressure Ulcer Advisory Panel (NPUAP), we know that "healed" Stage III and Stage IV pressure ulcers are "closed," not healed, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates and CoDR - Coding Done Right in Denton, Texas. When it comes to applying the guidelines, home care coders will still code a closed Stage III and IV. You will not code a healed Stage I or II. A healed Stage I or Stage II is no longer considered a pressure ulcer, she says.

OASIS C instructions have clarified "healed" and "closed" for home care coders, Selman-Holman adds. As of Jan. 1, 2010, item M1306 asks whether the patient has any unhealed pressure ulcers Stage II or higher. The OASIS C guidance goes on to explain that Stage III and IV pressure ulcers can never be considered fully healed, but can be considered closed. The guidance from NPUAP is longstanding and Medicare adopted NPUAP's guidance as OASIS guidance more than a year ago.

Note: It's unlikely that a closed stage III or IV pressure ulcer would be the main reason for home health admission so it would be rare to see the code in M1020, experts say.

Many coders are confused by the term "open wound," Twombly says. If you're coding for a dehisced wound, or a Stage IV pressure ulcer where you can see down to the bone, you might think that you're coding for an open wound, but in ICD-9 coding that's an incorrect assumption.

Open wounds are actually trauma wounds, Twombly says. If the wound wasn't created as a result of trauma such as a laceration, puncture wound, cut, avulsion, or animal bite, it's not appropriate to list a code from the 870.x-897.x (Open wounds) categories.

On the other hand: Complicated surgical wounds occur when a surgical wound isn't healing as expected. Something has caused the surgical wound to become complicated. Non-healing, infected, and postoperative fistulas are all examples of complicated surgical wounds.

Oftentimes, physician referrals will say something like "ulcer of lower extremity," says Matt Santangelo, RN, BSN, COS-C, HCS-D, with FirstLantic Healthcare in Fort Lauderdale, Fla. When that's the case, the nurse must do her best to assess the wound and gather more details for coding.

Trauma wounds (those caused by falls or hitting bed frames or wheelchairs) can be easiest to identify, but determining the cause of an ulcer can be trickier. If there's no definite answer from the assessment, talk to the doctor, Santangelo says. He can tell you if the patient's diabetes caused the ulcer, or if the patient's venous insufficiency caused a stasis ulcer. The doctor knows your patient's history and is your best resource for researching wounds, he says.