Determining Wound Diagnosis and Documentation Tips Job Aid

Transcription

1 Determining Wound Diagnosis and Job Aid 1 Coding Is this a traumatic injury from an accident? 800 Codes - Injury Section of the Coding Manual Code by specific site of injury. Only use for accidents or intentional violence. Code the most serious injury first. Never use for surgeries or amputations performed for treating disease. Add V58.30 Encounter for intervention was required. Add V58.31 Encounter for change or removal of surgical when a surgical intervention is required. The decision of whether to code the trauma or use a V- code as the primary diagnosis will depend upon whether the dressing change is the focus of the POC. Use M0246 for any case mix diagnosis replaced by a V-code to obtain proper reimbursement. Open wound r/t trauma, injury or burn The traumatic wound must be the main focus of the POC to be the primary diagnosis. V-code can only be used if we are attending to dressings and sutures. Without dressing changes, the injury codes would be the most specific code available. Traumatic wounds are acute wounds, as opposed to chronic wounds, such as diabetic foot ulcers or venous leg ulcers. Case mix points scored: Primary Dx Skin 1 Other DX Skin 2 Primary Dx or Other Dx, Skin 1 or Skin 2 and M0250 Documentation should explain the type of accident or injury. Investigate if another payer is responsible as the primary payer over Medicare. (Determination of Primary Payer form is the Company decision tree that will lead you to the correct payer selection.)

2 Determining Wound Diagnosis and Job Aid 2 Coding Is the wound superficial? Superficial Injuries Section of the Coding Manual These codes do not add points to HHRG. Superficial wounds Note: Superficial wounds are rarely used as the primary diagnosis. Use for superficial injuries such as abrasions, blisters, and insect bites. A V-code would not be appropriate because dressing changes to shallow wounds rarely require skilled care. Superficial wounds have very limited coverage without complications. Care for a superficial wound would not be complex enough to require the skills of a nurse or have high probability of change. OASIS Completion Job Aid will help answer M0 questions objectively.

3 Determining Wound Diagnosis and Job Aid 3 Coding Is the wound a skin tear? Limbs code by specific site in the 800 Injuries Section of the Coding Manual Other possibilities for nonlimbs: Other wound (except limbs), unspecified site, uncomplicated Other wound (except limbs), unspecified site, complicated. Add V58.30 Encounter for wound dressing only if the skin tear is not complicated. Open wound by specific site. Rarely used as a primary diagnosis. A wound caused by trauma must be coded as trauma even if it is minor. The skin tear must be the main focus of the POC to be the primary diagnosis. A V-code would not be appropriate because dressing changes to shallow wounds rarely require skilled care. Category 870 codes add points to clinical domain Skin 1 diagnosis. Assign only if wound is due to accident or violence - trauma Very limited coverage. Dressings would not be complex enough to require the skills of a nurse. Observation not normally covered unless the tear is large or there are comorbid diseases, such as diabetes or PVD, that have a high probability of adversely affecting healing; even then, coverage would likely be limited to a few visits to teach. Trauma diagnosis carries increased coverage scrutiny due to additional reimbursement points.

4 Determining Wound Diagnosis and Job Aid 4 Coding Is the wound from a burn? 941.XX* Burn of head/face/neck 942.XX* Burn of trunk 943.XX* Burn of arm 944.XX* Burn of hand & wrist 945.XX* Burn of leg 948.XX* Burn by % of body surface 949.XX* Burn unspecified Add V58.30 Encounter for intervention is required. Add V58.31 Encounter for change or removal of surgical when a surgical intervention such as excisional debridement is required. Assign code as additional code for any documented infected burn site Base specific code selection on burn location. The burn must be the main focus of the POC to be the primary diagnosis. Use M0246 for appropriate case mix diagnosis replaced by a V-code to obtain proper reimbursement. Any injury caused by electricity, heat, chemicals, radiation, or gases. Burns are rated according to how many layers of skin are damaged. Category codes add points to the clinical domain Skin 1- Traumatic wounds, burns, and postoperative complications points for diagnosis Burns are rated, not staged. Most coding manuals contain a good diagram for estimating the amount of total body surface burned.

5 Determining Wound Diagnosis and Job Aid 5 Coding Is the wound a closed surgical site requiring only routine post operative wound care? V58.31 Encounter for change or removal of surgical as a secondary diagnosis when one or more visits are required for removal of surgical dressings. V58.32 Encounter for removal of sutures as a secondary diagnosis when one or more visits are required for the removal of sutures. V-code more accurately reflects the reason homecare is to be provided. Do not code as a trauma. Use M0246 for any appropriate case mix diagnosis replaced by V- codes to obtain proper reimbursement. Code the surgical procedure under the surgical category. The underlying disease requiring surgery becomes an outdated diagnosis. It can be added as a secondary diagnosis if needed to complete the picture, although it should be listed after other pertinent diagnoses that are the focus of the POC. M mark M # of surgical wounds M0486 non observable M0488 status of most problematic wound Additional points for early/partial granulation and not healing points if surgical wound shows early/partial granulation or is not-healing The appropriate V code for Aftercare following surgery is the primary diagnosis (V58.4x) Document the status and progression of healing for wounds associated with a surgical intervention. Very limited coverage since dressing would not be complex. Limited visits to teach would be covered. A surgical incision with approximated edges and a scab (i.e. crust) from dried blood is considered a current wound. Old surgical wounds which have resulted in scar or keloid formation are not considered current surgical wounds. OASIS Completion Job Aid will help answer M0 questions objectively.

6 Determining Wound Diagnosis and Job Aid 6 Coding Does the wound or surgical site have a complication? Disruption of internal operation wound Disruption of external operation wound Post-op infection Persistent post-op fistula Non-healing surgical wound Or code with 900 codes by specific site of injury or by complication Only use when there is a wound complication. V codes for wound care are never included as part of the coding when complications are present. Codes frequently include an option for complications. Physician documentation must support that a complication exists. A V-code is not selected as the primary diagnosis when an acute diagnosis, such as post operative complications, is the focus of the POC. V-codes are primarily used to explain the need for aftercare with a resolving disease injury. Code 998.3x adds points to the clinical domain as a Skin 1 diagnosis M mark M # of surgical wounds M0486 Non Observable surgical wound M Status of most problematic wound. Additional points for early/ partial granulation; not healing. points if surgical wound shows early/partial granulation or is nothealing Wound complication requires documentation of the specific complication such as a major infection, delayed treatment or healing, tissue loss, dehiscence, or presence of foreign body. Assessment should support status of wound. Early/Partial granulation: > 25% of the wound bed is covered with granulation tissue, < 25% of wound bed is covered with avascular tissue, may have dead space but no signs and symptoms of infection. Not healing: >25% avascular tissue (eschar and/or slough) OR signs/symptoms of infection OR clean but non-granulating wound bed OR Closed/hyperkeratotoc wound edges OR persistent failure to improve despite appropriate comprehensive wound management OASIS Completion Job Aid will help answer M0 questions objectively. A soft tissue infection or abscess (e.g., 686.X) treated by incision and drainage (I&D) is not considered a surgical wound. The underlying condition requiring surgery is the primary diagnosis.

7 Determining Wound Diagnosis and Job Aid 7 Coding Is the wound a result of pressure? 707.0X Decubitus Ulcer (Requires a fifth digit to designate ulcer site) Unspecified Site Elbow Upper Back Lower Back Hip Buttock Ankle Heel Other Site To indicate the stage of the ulcer, add a code from 707.2x. Add V58.30 Encounter for intervention is required. Decubitus Ulcer Referred to as: Decubitus ulcer, bedsores, and pressure ulcers. Pressure ulcers are defined as localized areas of tissue necrosis that develop when soft tissue is compressed between a bony prominence and external surface for a prolonged period of time. Pressure ulcers are coded by location. When a patient has more than one, assign a code for each pressure ulcer site. M mark M0450 Additional points for 2 or more stage 3 or 4 ulcers points M0460 stage of most problematic ulcer Additional points received depending on ulcer stage The stage of the wound, amount and type of drainage, and the type of dressing will determine the need for skilled visits. Documentation needs to address pressure relief (repositioning q2h and pressure relieving support surfaces on bed and/or chair), adequate nutrition (hi protein, hi cal diet within limits of ordered diet), and incontinence care (if incontinent of urine or feces). If patient is unable to turn, adequate caregiver needed in the home for turning. A debrided pressure ulcer does not become a surgical wound. OASIS Completion Job Aid will help answer M0 questions objectively.

8 Determining Wound Diagnosis and Job Aid 8 Coding Does the patient have a diabetic ulcer of the lower limb? 250.8X * Diabetes mellitus with other specified manifestations 707.1X* - Ulcer of lower limbs Add V58.30 Encounter for intervention is required. The underlying condition (diabetes) is coded as primary diagnosis and the ulcer is coded as the secondary diagnosis. This is also referred to as the manifestation code. Use M0246 for any case mix diagnosis replaced by a V- code to obtain proper reimbursement. Follows the unique coding instructions in the ICD-9 coding manual. This recognizes that the ulcer results from complications of diabetes over an extended period of time. Diabetes affects circulation as well as the nerve endings in the feet. As a result, many diabetics suffer from reduced circulation and loss of sensation. Due to the loss of sensation, patients are unable to feel rubbing, pinching, or other pain that could cause a wound to develop. M0230 with diabetes as primary diagnosis ICD-9 codes M0240 with ulcer as the first secondary diagnosis Codes in 707.1x subcategory add points to the clinical domain as Skin 2 diagnoses points Because the wound is the most acute condition, document the teaching and treatment provided. Any changes in the diabetic condition should also be noted. Since these ulcers are typically on the plantar foot, document any ADL limits and footwear to achieve off-loading and BS levels to support healing. Codes from this category add points to the clinical domain as Diabetes diagnoses. Several manifestations of diabetes are also case-mix manifestation codes. When 250.7X is used diabetes is not coded first since the ulcer would not be a manifestation of diabetes.

9 Determining Wound Diagnosis and Job Aid 9 Coding Does the patient have atherosclerosis of the extremities with ulceration? Atherosclerosis of the extremities with ulceration Use additional code for any associated ulceration Ulcer of lower limbs V58.30 Encounter for intervention is required. There are no specific OASIS M0 items related to assessment of arterial ulcers. The underlying condition (atherosclerosis) is coded as the primary diagnosis and the ulcer is coded as the secondary diagnosis. This is also referred to as the manifestation code. Follows the unique coding instructions in the ICD-9 coding manual. This recognizes that the ulcer results from complications of atherosclerosis over an extended period of time. This code adds points to the clinical domain as a Skin 2 diagnosis points No specific M0 questions for arterial ulcers Since these ulcers are typically painful, document any pain control measures. Moist wound healing may be contraindicated for dry, stable ulcers on ischemic legs until after revascularization. Compression may be contraindicated, depending on the degree of arterial insufficiency.

10 Determining Wound Diagnosis and Job Aid 10 Coding Does the patient have venous stasis of the extremities with ulceration? 454.X* Varicose veins with stasis ulcer. No additional code for the ulcer is required Venous (peripheral) insufficiency, chronic venous insufficiency (NOS code any associated ulcer) Ulcer of lower limbs V58.30 Encounter for intervention is required. The underlying condition is coded as the primary diagnosis. The ulcer is included in the 4 th digit with 454.X or the ulcer is coded separately if is the primary diagnosis. Venous ulcers are shallow, irregularly shaped ulcers that often appear beefy and red. Typically, they are located below the knee, usually inside the legs just above the ankles. However, they can occur almost anywhere on the lower legs. The decision to use a V- code as the primary diagnosis will depend upon whether the dressing change is the focus of the POC. Follows the unique coding instructions in the ICD-9 coding manual. This recognizes that the ulcer results from complications of venous stasis over an extended period of time. Venous leg ulcers are related to chronic venous insufficiency, a condition in which the veins in the leg are inadequate at pumping blood back toward the heart. As a result, fluid and blood products leak through the vessel walls into the surrounding tissue. Stasis ulcers do not include arterial circulatory lesions or arterial ulcers. MO468 - mark M # of ulcers M Stasis ulcer that cannot be observed M0476 status of most problematic ulcer Additional points for early/partial granulation or not healing. points Since these ulcers are typically associated with lower extremity edema, document any edema control measures (elevation, compression, and ambulation). OASIS Completion Job Aid will help answer M0 questions objectively. *X indicates the required additional digit