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Try This Wound Coding Workout

Published on Tue Aug 17, 2010 Print Friendly and PDF PDF

Choose the right aftercare code for fractures repaired by joint replacements.

Last month's article, 4 Questions Clear the Way to Better Wound Coding (Vol. 7, No. 8), gave you an opportunity to brush up on your wound coding skills. Put your knowledge to the test with these wound coding scenarios.

Case 1: While in the kitchen, Mrs. G. scraped her arm against the stove and sustained a significant skin tear on her forearm. The injury is 4 inches long and 2 inches wide. The injury has bled a significant amount. Mrs. G's doctor has ordered nursing to provide the following wound care regimen two to three times a week: wash with normal saline, apply bactroban, Opsite and wrap with kling. How would you code for this patient?

Case 2: Mr. W was admitted to the hospital for acute appendicitis and underwent an appendectomy. He returned home for wound care and assessment of the incision site. Nursing will do the  dressing one time a week and will teach the family to change every other day and which symptoms to report. Mr. W will continue on his medication for hypertension and atrial fibrillation with labs every month for PT/INR.

Case 3: Mrs. A. was admitted to an acute care facility to undergo a coronary artery bypass graft (CABG) of three coronary arteries due to coronary artery disease (CAD). She is home following the surgery and requires daily care to chest incision site due to external dehiscence of operative wound.

Case 4: Mrs. Q fractured her hip when falling from the curb. It was repaired by total hip replacement. She is admitted for physical therapy and skilled nursing will also see the patient. She has a history of osteoarthritis, congestive heart failure, hypertension, chronic renal insufficiency, and chronic systolic heart failure

Case 1 Answer: For this patient, you would report 881.0x (Open Wound of elbow, forearm and wrist) in M1020a says Joan L. Usher, BS, RHIA, COS-C, ACE, with JLU Health Record Systems in Pembroke,

Mass. This skin tear is a true traumatic wound, so it's appropriate to code for it from the open wound category.

Case 2 Answer: In this case, the focus of your care is aftercare following the patient's surgery, says Usher. Code for this patient as follows:

M1020a: V58.75 (Aftercare following surgery of the teeth, oral cavity and digestive system);

M1024 540.9 (Acute appendicitis; without mention of peritonitis);

M1022b: V58.31 (Encounter for change or removal of surgical wound dressing)

M1022c: 401.9 (Essential hypertension; unspecified);

M1022d: 427.31 (Atrial fibrillation); and

M1022e: V58.83 (Encounter for therapeutic drug monitoring)

M1022f: V58.61 (Long term [current] use of anticoagulant).

You are doing more than simply changing this patient's dressings, so listing an aftercare code as primary is appropriate. List 540.9 in M1024 because the underlying reason for the surgery (appendicitis) was resolved by the surgery.

Your secondary diagnoses for this patient include atrial fibrillation and hypertension, along with the V codes for dressing changes and therapeutic drug monitoring. The sequencing of the additional V codes is discretionary so they can be moved down your diagnosis list.

Case 3 Answer: Your focus of care for this patient is her dehisced operative wound. Code for her as follows, Usher says:

M1020a: 998.32 (Disruption of external operation [surgical] wound);

M1022b: V45.81 (Aortocoronary bypass status); and

M1022c: 414.00 (Coronary atherosclerosis of unspecified type of vessel, native or graft).

Following the principal diagnosis (998.32) for this patient, you should also indicate that her status postbypass graft (V45.81). Although the wound is dehisced, the graft is still good. The surgery didn't cure her CAD, so list 414.00 to indicate this.

Case 4 Answer: Code for this patient as follows, says Tricia A. Twombly, BSN, RN, HCSD, CHCE, senior education consultant and director of coding with Foundation Management Services in Denton, Texas.

M1020a: V54.81 (Aftercare following joint replacement); M1024: 820.8 (Fracture of unspecified part of neck of femur, closed);

M1022b: 781.2 (Abnormality of gait);

M1022c: 403.90 (Hypertensive chronic kidney disease; unspecified; with chronic kidney disease stage I through stage IV, or unspecified);

M1022d: 585.9 (Chronic kidney disease, unspecified);

M1022e: 428.0 (Congestive heart failure, unspecified);

M1022f: 428.22 (Systolic heart failure; chronic);

Other pertinent diagnoses:

715.09 (Osteoarthritis, generalized; multiple sites);

V43.64 (Organ or tissue replaced by other means; hip); and

E880.1 (Fall on or from sidewalk curb).

When a joint is fractured and repaired by a joint replacement, you should report an aftercare code for a joint replacement rather than an aftercare code for a fracture, Twombly says. The only place you can report the fracture code is in M1024 because coding guidelines prohibit reporting an acute fracture on a home health claim.

Read the fine print: An excludes note was added this last year to the aftercare for fracture code series explaining you cannot use an aftercare for fracture code if you are coding the fracture as having been repaired with a joint replacement, Twombly points out.

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