OASIS Alert

Remember: Complications nix aftercare.

The surgical wound codes you list in M1020 and M1022 depend on the answers to three questions. Make sure you know what it takes to choose the code most appropriate for your patient.

Answer 3 Questions for Surgical Wounds

When deciding how you should code a surgical wound, you'll need to answer three questions, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, HCS-O, consultant and principal of Selman-Holman & Associates in Denton, Texas. To select the most accurate codes, ask yourself:

• Should I list an aftercare code?
• Are there complications?
• Should I list aftercare for the surgical wound as a secondary code?

Choose Aftercare for Resolving Wounds

If the surgical wound has no complications and your agency will be providing normal and routine aftercare for a clean healing incision, you'll list an aftercare code to indicate the wound care, says Joan L. Usher, BS, RHIA, COS-C, ACE, president, of JLU Health Record Systems in Pembroke, Mass.

To find the correct aftercare code, you'll need to know the reason for the patient's surgery. Check the code description to see the range of codes listed for each of the aftercare codes. For example, -- V58.4x (Other aftercare following surgery) and V58.7x (Aftercare following surgery to specified body systems, not elsewhere classified), Usher says.

For example: Look to V58.42 (Aftercare following surgery for neoplasm) for conditions classifiable to 140-239. Choose V58.43 (Aftercare following surgery for injury and trauma) for conditions classifiable to 800-999.

Caution: Aftercare for traumatic fractures is excluded from V58.43 and should be reported instead with codes from V54.10-V54.19, (Aftercare for healing traumatic fracture ...).

V58.44 (Aftercare following organ transplant) is your go-to code for organ transplant aftercare. Finally, the V58.7x codes describe aftercare for surgery of specific body systems, not elsewhere classified.

If the condition responsible for your patient's surgery doesn't fit into one of the specific surgical aftercare codes, you can list V58.49 (Other specified aftercare following surgery) to indicate that you are providing aftercare.

Coding example: Mr. W was admitted to the hospital for acute appendicitis and underwent an appendectomy. He returns home for assessment of the incision site. List V58.75 (Aftercare following surgery of the teeth, oral cavity, and digestive system, NEC) in M1020a for this patient, Usher says. Because the appendicitis was resolved with surgery, you won't list it in M1020 or M1022. You'll only list 540.9 (Acute appendicitis; without mention of peritonitis) in M1010 -- Inpatient diagnosis.

Case mix: The code for appendicitis is on the case mix diagnosis list, so remember to list this code in M1024 across from the V code for GI points.

Tip: The ICD-10-CM code for "Encounter for surgical aftercare following surgery on the digestive system," Z48.815, is separate from the aftercare code for surgery on the teeth and the oral cavity.

Another example: Your patient has fibrocystic disease of the breast and has had surgery. Because this isn't a neoplasm, injury or transplant, you would look to the V58.7x codes to report this patient's condition, Selman-Holman says. In this case, V58.76 (Aftercare following surgery of the genitourinary system, NEC) is the right aftercare code. The notes next to V58.76 indicate that this is the right aftercare code for conditions classifiable to 580-629, and the reason for your patient's surgery was 610.1 (Diffuse cystic mastopathy).

Choose Complications Over Aftercare

When your patient experiences post-operative issues following surgery such as post--operative wound infections, non-healing surgical wounds, or dehiscence (which you would code as disruption of an operative wound), then the appropriate diagnosis to list is the wound condition, Usher says. When you're providing treatment to the patient's complicated wound, it's acute coding -- not aftercare, she says.

Caution: Confirm complications with the physician. Don't list a complication code based on an answer of "Not healing" on the OASIS-C at M1342 (Status of Most Problematic [Observable] Surgical Wound), Selman-Holman adds.

If you confirm that the surgical wound you're caring for is as complicated, it's not appropriate to list an aftercare code for surgery or a dressing change code because the care you provide isn't routine. Instead, look under "complications" in the alphabetic index and then confirm you've landed on the right code by checking it against the tabular list.

You'll find codes dedicated to specific complications in chapter 17 in categories 996.x (Complications peculiar to certain specified procedures), 997.0x (Nervous system complications) and 998.x (Other complications of procedures, not elsewhere classified). Always use the most specific code available to describe the actual surgical complication.

Coding example: Mrs. A. was admitted to an acute care facility to undergo a coronary artery bypass graft (CABG) due to coronary artery disease (CAD). She is returning home with orders for daily care to chest incision site due to internal dehiscence of the operative wound. Code for this patient as follows, Usher advises:

• M1020a: 998.31 (Disruption of internal operation [surgical] wound);
• M1022b: V45.81 (Postsurgical aortocoronary bypass status); and
• M1022c: 414.00 (Coronary atherosclerosis of unspecified type of vessel, native or graft).

Listing 998.31 will add HHRG points and non-routine medical supply (NRS) reimbursement to your payment for this episode, Usher points out. List the status code because the dehiscence is not affecting the bypass itself.

Some Surgical Wounds are Secondary

When your patient had surgery, but the focus of care is either the reason for the surgery or some other condition, you can list an aftercare code as secondary to indicate that you are providing wound care, Selman-Holman says.

Coding example: Your patient had her gall bladder removed due to acute cholecystitis. While in the hospital, she caught an acute bronchitis which exacerbated her chronic bronchitis and her hypertension. She has some small incisions from her gall bladder surgery, but the focus of care is the acute infection and the hypertension. Use the following codes for this patient, Selman-Holman says:

Don't miss: Although the cholecystitis is resolved because the patient no longer has her gall bladder (due to the surgery), listing 575.0 in M1024 makes you eligible for case mix points as well as risk adjustment, Selman-Holman says. But don't code for the cholecystitis in M1020 because the condition no longer exists, she says.

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