Inpatient Facility Coding & Compliance Alert

Question: We have a few patients who are receiving care in our wound center for trauma wounds that didn’t heal as expected. How do we know when a wound becomes non-healing for coding purposes? And how do 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. But you can’t report a wound as non-healing unless the physician confirms the complication diagnosis. The Official ICD-9-CM Guidelines for Coding and Reporting require the physician to determine whether a complication exists and establish the cause and effect relationship between the care and the complication.

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 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.