Eli's Rehab Report

Question: Our home health patient had a total knee replacement. The OASIS Assessment completed two weeks later indicates that the incision line is well approximated, with two small areas of incisional separation and a moderate amount of serosanguineous drainage which has not changed in appearance in 14 days. Skilled nursing is ordered for wound care and physical therapy is ordered for gait training. How should we code for this patient?

Answer: The patient is progressing in therapy as expected, so you can list aftercare code V54.81 (Aftercare following joint replacement) and status code V43.65 (Organ or tissue replaced by other means; knee joint) for the PT services, says Jan M. McLain, RN, BS, LNC, HCS-D, COS-C, with Adventist Health System, Home Care Corporate Services in Port Charlotte, Fla.

But this wound displays signs of delayed healing. It’s not progressing as it should, so you should contact the physician regarding the status of the wound and report the incisional separation and the drainage. If the physician agrees, you could code for it as non-healing with 998.83 (Non-healing surgical wound) or 998.32 (Disruption of external operation [surgical] wound), McLain says.

This coding looks strange because you would be including both an aftercare code (indicating routine care) and a surgical complication code, notes Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, HCS-O, consultant and principal of Selman-Holman & Associates in Denton, TX. In this case, the wound is complicated, but otherwise the aftercare for the joint replacement is routine, she says.

Caution: You cannot list this as non-healing wound unless the physician confirms the complication diagnosis, warns Judy Adams, RN, BSN, HCS-D, COS-C with Adams Home Care Consulting in Chapel Hill, N.C. In this particular case, you may find that the physician isn’t willing to consider the wound as non-healing just because it is having some prolonged drainage, she warns.

The Official ICD-9-CM Guidelines for Coding and Reporting effective 10/1/11 require the physician to determine whether a complication exists and establish the cause and effect relationship between the care and the complication, Adams says.

On the other hand: If the wound complication was more than superficial and involved the prosthesis itself, you would list 996.66 (Infection and inflammatory reaction due to internal joint prosthesis), says Selman-Holman. In this scenario, you wouldn’t list an aftercare code because the care of this joint replacement patient is not routine.

In either case, be sure to include the V43.65 code for knee prosthesis status, unless the prosthesis has been removed because of the infection, Selman-Holman says. In that case, list V88.22 (Acquired absence of knee joint) instead of V43.65.