Home Health ICD-9/ICD-10 Alert

Question: When does a wound become non-healing or chronic for coding purposes? We have had patients who were receiving care for trauma wounds that don't heal as expected. If the physician documentation indicates that a traumatic wound has become chronic, how would we code for it?

-- New York Subscriber

Answer: A complicated trauma wound is defined as one that has delayed healing, delayed treatment, the presence of a foreign body or infection.

If a trauma wound is complicated, it usually only requires a change to the fourth digit. For example, 891.0 (Open wound of knee, leg [except thigh], and ankle; without mention of complication) describes a trauma wound to the leg (except thigh). Change the fourth digit to "1" for 891.1 (... complicated) to indicate that the trauma wound is complicated.

Unless otherwise indicated, reader questions were answered by Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates in Denton, TX.