Wiki How to Code for a Non-Healing Surgical Wound without Complication/Sequela/Infection

nicoleysmith

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I have been reading the many threads on the forum regarding a non-healing/delayed-healing surgical wound, but none quite fit my situation (of note: I work in a clinic where the provider enters their codes and a coder checks them).

Patient had a MOHs surgery for removal squamous cell carcinoma in December 2019.
Patient has a follow-up with the MOHs surgeon in February 2020 with a chief complaint of "Check surgery site" and an HPI of "surgical site much improved, but healing seems to have stalled"

Physical findings list the patient's height and "surgical scar on the left helix - very tender to the touch, small crust/scab"
Office procedures list "Office Procedures 1. non healing wound - infection vs CDNH - wound culture today- may do steroid injection next week if wound culture negative 2. wound on the right cheek - BCC vs irritation from CPAP machine - consider biopsy if doesnt heal"

Documentation also lists Active Problems & Current Medications.

Provider has coded 11042, C44.229.
Aerobic bacterial culture was ordered with C44.229.

Questions:
1. is that enough documentation to code for a debridement?
2. how do I code a diagnosis of "non-healing wound" when there is no definitive malignancy, infection, surgery complication, or late effect of the original neoplasm?
3. Can I code diabetes mellitus from the active problem list as a co-morbidity even if the dermatologist doesn't address it?

I recently started coding MOHs and the documentation is sparse, so any help is greatly appreciated. This one is tough! :)
 
1) No, not enough to code debridement
2) I would code T81.89X with A, D, S for non-healing surgical wound
3) If the DM is documented, I would code it here. I would also advise my provider for the future to put in a sentence about DM if he/she believes it was impacting the healing process.
4) Regarding billing an OV for the cheek, take your note and cross out anything that was part of the postop global visit. See if you have anything billable left and code that. MAYBE you have a 99212.
Hope that helps.
 
It looks he/she took a culture to rule out "infection vs. CDNH" and the documentation listed above does not show that a debridement per sq cm was done. The CPT code 11042 is- Debridement, subQ tissue; first 20 sq cm or less. How much did he debride or did he just scrape it for a culture?

It also states in our CPT guidelines state that "Debridements are reported by the depth of tissue that is removed and by the surface area of the wound." (PG 79, 2020 CPT book)

An active problem list can be appropriate for a chronic condition unless stated that this no longer an issue.
 
The documentation doesn't state there was any debridement at all - I don't think I can code for it. This was within the 90 day global for MOHs, but the provider treats both the post op wound (with the culture on an ear) and looks at a separate issue (wound on cheek). Can I code an OV for the cheek since it isn't related to the MOHs wound?
 
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