Home Health ICD-9/ICD-10 Alert

Question: Our patient has an open wound on her right lower leg. The surrounding tissue is darkened and she has varicose veins. We will be cleansing the wound, covering it with gauze, and wrapping or securing it with tape. When we queried the physician for more details on the wound, he indentified it as a stasis ulcer associated with varicose veins with stasis dermatitis. How should we code for her?

New Jersey Subscriber

Answer: Before you contacted the physician, you might have coded this wound with three codes: 891.1 (Open wound knee leg, [except thigh], and ankle; complicated), 682.6 (Other cellulitis and abscess; leg, except foot), and 454.0 (Varicose veins of other extremities; with ulcer).

Remember: Skin 1 case mix diagnosis 891.1 is eligible for additional points for your care of the open wound.

But after making your call to the physician, you gathered greater details about the wound. This allows you to select a more precise code to describe your patient’s wound: 454.2 (Varicose veins of other extremities; with ulcer and inflammation).

This code won’t earn case mix points, but your coding is more specific. With the added details, you can provide appropriate treatment to the wound. Plus, you won’t risk a denial for up-coding because now the documentation supports the code you selected.