OASIS Alert

Your patient may consider her surgery traumatic, but the government doesn't.

If your clinicians still mistakenly are using 800- and 900-series trauma codes to describe wounds on M0230, the trauma could soon be yours. And you're not alone. "That's the biggest issue I see with wound care," declares Melinda Gaboury with Healthcare Provider Solutions in Nashville. Agencies are seeing more additional development requests on claims with trauma codes as the primary diagnosis, and some are even being put on post-payment reviews because of continued misuse of the codes, she adds.

Regional home health intermediaries are cracking down on misuse of open wound trauma codes because these codes add points to the patient's Health Insurance Prospective Payment System (HIPPS) code setting the reimbursement rate for that episode. If you answer "yes" to M0440 "Does the patient have a skin lesion or open wound" and enter a trauma code as the primary diagnosis in M0230, "21 points will be allowed toward the HIPPS score," explains Palmetto GBA in its document The Appropriate Use of Burn/Trauma Codes.

And this can add up to a substantial sum to which you're not entitled. For example, using the open wound code instead of the correct diabetes code for a diabetic skin ulcer could give you more than $300 in improper reimbursement, Gaboury illustrates. And the government will be busily tracking down these mistakes and demanding their money back.

Tip: To avoid bringing the feds to your door, remind clinicians that the open wound codes included in the ICD-9 manual's chapter on injury and poisoning are reserved for injuries due to accidents or violence, Palmetto explains (see flow chart, article 11). "It is very important to always clearly describe the cause of any open wound in your documentation," Palmetto adds.

A surgical wound could qualify for an open wound code if the trauma or injury caused the open wound and the surgery repaired the wound, Gaboury instructs. But if you're caring for an incision caused by a mastectomy for breast cancer, the correct primary diagnosis code is for breast cancer, not for an open wound to the chest, she emphasizes.

Trauma codes could be appropriate where the patient is admitted to home care due to a fall, advises RHHI United Government Services in its Home Health Training Manual.

Clinicians often are baffled as to why they can't use these codes, experts say. "Nurses unfamiliar with ICD-9 coding always put the trauma codes, because they often describe the wound better than other ICD-9 codes," warns Pam Warmack, president of Clinic Connections in Ruston, LA. Before the prospective payment system, "the aim was to be more descriptive, rather than to code for payment," she notes.

Theoretically, errors in using trauma codes should decrease once V codes are allowed on the OASIS assessment in October, but "alot depends on education," predicts Sue Prophet-Bowman, director of coding policy and compliance with the American Health Information Management Association in Chicago. The V code provides a way to "appropriately describe normal postoperative wound care," but that alone won't resolve coding errors, she says. Clinicians will need to learn how and when to properly use V codes, since coding errors "show lack of understanding of the proper application of the coding system," she tells Eli.

Nurses new to OASIS have a tremendous amount to remember, Warmack says. Stress the appropriate coding of wounds at orientation and emphasize it in continuing education as well, she advises.

Tip: Written exams following training sessions will give you some idea of what nurses learned, Warmack says. But the best test is practical application reviewing their assessments and discussing their answers, she adds. Monitor the assessments of new nurses until the nurse demonstrates consistent correct choice of primary and secondary diagnoses, she suggests.

Editor's Note: Prinny Rose Abraham will present a teleconference sponsored by Eli Research covering V codes, M0245 and other coding strategies May 22. For information or to sign up, go online to www.eliresearch.com and click on 'Teleconferences.'