Home Health ICD-9/ICD-10 Alert

Question: Our patient has been recertified after 60 days due to a surgical wound not healing. My supervisor said we should use V58.3 even though it's after 60 days because the physician didn't clarify that the wound is non-healing. Is partial granulating the same as non-healing?


California Subscriber

Answer: A non-healing wound is a wound that is not progressing despite appropriate treatment. It may have separated edges, hyperboled edges or show signs of infection. Follow the Wound, Ostomy and Continence Nurses Society guidelines, which CMS has adopted to determine the status of the wound. If it is truly not healing, then code it as 998.83 (Non-healing surgical wound). If the wound is at early/partial granulation status, continue using the V code for aftercare followed by V58.3 if performing dressing changes.

Example: Your patient had surgery for a popliteal-femoral bypass performed for peripheral vascular disease. To code for this patient, report V58.73 (Aftercare following surgery of the circulatory system, NEC), followed by V58.3 (Attention to surgical dressings and sutures).

Note: For more about the WOCN guidelines go to http://new.cms.hhs.gov/apps/hha/42304ho3.pdf.