Wiki Wound Care Coding - I am coding for our wound

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mgotti21773

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I am coding for our wound care clinic this week and am wondering if someone can answer a question for me. The wound care doctors never tell us the severity of the wound..as far as
1. Bone Necrosis
2. Fat Layer Exposed
3. Muscle necrosis
4. Skin breakdown only
5. Unspecified.

I have used the unspecified code since that is the documentation I get and it bounces back every time. What I am wondering is if there is a way to look at what was charged and figure out the code I need? Someone in my office said that 11042, subcutaneous debridement = Fat layer exposed but I cant find documentation of that translation anywhere. If anyone could answer I would so appreciate the help. Thank you!

Marcia
 
If the description of the wound cannot give you the information of the wound specifics then the documentation is incomplete and should go back to the provider. If there is not enough information to get the diagnosis, then you probably did not have enough to support the procedure code.
 
Debra,

They typically only say something like the following...."The wound(s) was excisionally debrided sharply of fibrotic, necrotic, and hyperkeratotic tissue, including a layer of surrounding healthy tissue using curette for a total surface area of <20 cm2. The wound was debrided down through and including subcutaneous."

Which isn't enough to figure out the severity, correct? I just want to get this straight before I present it to my boss, as I said, I am a new coder and was taught by more experienced coders and don't want to step on toes if I don't have to.

Thanks for your quick reply.

Marcia
 
It is not a great description of the wound, I would like more detail if it was me. He did state necrotic tissue, but I also wonder if that was a template statement. I would request more description of the actual wound.
 
The problem is, they send every single chart over like this. There is never enough documentation in my opinion. I am going to mention it to my boss and see what happens. Can only help I guess.

Thanks again
Marcia
 
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