Home Health ICD-9/ICD-10 Alert

Question: Our patient had a total knee replacement on 5/1/12. The OASIS Assessment completed on 5/3/12 indicates that the incision line on the knee is well approximated, with two small areas of incisional separation and a moderate amount of serosanguineous drainage. Skilled nursing is ordered for wound care and physical therapy is ordered for gait training. How should we code for this patient?

Answer: Even though those small areas of incisional separation may make that wound "not healing" on the OASIS M1342 (Status of Most Problematic [Observable] Surgical Wound) depending on the amount of granulation that can be seen, you cannot code this wound as a dehisced surgical wound (998.32) without physician documentation. In this case, the physician is not likely to agree with coding this wound as complicated.

Instead, code for this episode as routine aftercare for joint replacement with V54.81 (Aftercare following joint replacement), says Jan M. McLain, RN, BS, LNC, HCS-D, COS-C, with Adventist Health System, Home Care Corporate Services in Port Charlotte, Fla.

When a surgical wound has no complications and your agency is providing normal and routine aftercare for a clean healing incision, you'll list an aftercare code to indicate the wound care. Because your patient had a joint replacement, you'll look to V54.81 to describe the aftercare you provide.

You should also list status V code V43.65 (Organ or tissue replaced by other means; knee joint) to indicate the specific joint replaced.