Wound Care Documentation and Coding

Hello everyone and welcome to our podcast series. My name is Natalie Tornese and I am the Senior Group Manager for Outsource Strategies International. Wanted to take this opportunity to discuss different types of wounds, their causes, symptoms, treatment options, documentation requirements, and medical coding.

Wounds that damage the skin include abrasions, lacerations, scratches, rupture injuries, punctures, and penetrating wounds. They often occur due to accidents or falls. However, surgeries, stitches, sutures or even complications related to other conditions such as diabetes can also cause certain types of wounds. Minor wounds generally are not serious. However, serious and deep infected wounds may require immediate medical attention to prevent the chances of infection and loss of function.

01:00 Importance of Proper Wound Care

Regardless of the type of wounds and how they occur, it is important to receive proper wound care with effective, immediate treatment and ongoing diligence. Wound care covers wound treatment as well as evaluation and management (E/M). If left untreated, wounds can become chronic and significantly affect the individual’s quality of life and prevent people from doing things they enjoy. Physicians treating different types of wound conditions must clearly document the diagnosis and other medical procedures performed using the correct medical codes.

01:35 Common Wound Types

Common types of wounds include –

• Acute wounds which occur due to a disruption of the skin or underlying soft tissue.
• Chronic wounds, which is when acute wounds do not heal properly, they can become chronic. This is particularly dangerous for the elderly. When an acute wound transforms into a chronic wound it can cause an infection, ulcers and inflammation. All chronic wounds begin as acute wounds and generally include vascular ulcers, pressure ulcers and diabetic ulcers.
• Open wounds are commonly caused by falls or accidents with sharp objects or tools. Open wounds refer to injuries that involve an external or internal break in body tissue, mainly the skin. Common open wounds will include lacerations, abrasions and punctures.
• Closed wounds are a type of wound with intact skin, and underlying tissue that does not get directly exposed to the outside environment. Common wounds of this type include contusions, hematomas and crash injuries.

02:39 Wound – Diagnosis

Diagnosing wounds may begin with a detailed physical exam where physicians may inspect the type of wound, its severity and associated symptoms. Imaging tests like X-ray, fluoroscopy and ultrasounds may be performed to analyze the root cause of the condition and determine the correct treatment options. By performing these tests, physicians will check whether there is an associated injury with the wound. Understanding the previous history and the circumstances of the injury is crucial for determining the correct treatment and other after care required.

03:13 Wound Care Treatments

Most types of wounds can be easily cared for at home. Abrasions and lacerations can be easily cleaned and bacterial ointment can be applied and then covered with a bandage. In case any bleeding occurs, it can be easily controlled with direct pressure to the wound and if possible, elevating the bleeding site above the level of the heart. Treatment for different types of wounds or skin damage include assessment, management, and cleansing of the wound, simple debridement, and removal and reapplication of the wound dressings.

Treatments for different types of wounds may depend on several factors like the type of injury, the extent, the circumstance, the time frame from when the initial injury occurred and when the medical care was sought. In some cases, people with diabetes, poor circulation, people on dialysis, or people taking medications that compromise the immune system may be at higher risk for suffering infections. Treatments can involve sutures (stitches) for wounds and also prescription antibiotics. As part of the treatment, the health care professional will clean the wound and then check for foreign bodies or underlying structures that may have been damaged prior to closing the wound with sutures or staples. Antibiotics may also be prescribed if underlying structures like tendons or bones are involved. For traumatic injuries (chronic wounds and ulcers), a surgical intervention including debridement may be necessary.

Active wound care procedures involve removing devitalized and/or necrotic tissue to promote healing. Healthcare providers while treating different types of wounds must correctly document the related symptoms and causes.

Diagnosis codes for open wounds are grouped on the basis of anatomic location on the body as well as the type of wound. Codes for open wounds are found consistently across the body sites. The types of open wounds classified in ICD-10 are laceration without foreign body, laceration with foreign body, puncture wound without foreign body, puncture wound with foreign body, open bite, and unspecified open wound. There are some more specific codes for wound of the knee and lower leg which I will include in the transcript along with this podcast.

Wound debridement is a medical procedure that removes infected, damaged, or dead tissue to promote healing. Debridement or other treatment services can be billed when extensive cleaning of a wound is needed prior to the application of primary dressings or skin substitutes placed over or onto a wound that is attached with secondary dressings.

05:51 Codes for Reporting Wound Debridement

Wound debridement is coded as follows –

• Wounds Not Involving Subcutaneous Tissue will be coded 97597 for the first 20 sq cm and then an add on code of 97598 for each additional 20 sq cm
• Wounds Involving Subcutaneous Tissue, you would use code 11042 for the first 20 sq cm or less and then use the add-on code of 11045 for each additional 20 sq cm
• Wounds Involving Muscle and/or Fascia, 11043 for the first 20 sq cm or less and then use the add-on code of 11046 for each additional 20 sq cm
• Wounds Involving Bone, you would use 11044 Debridement of the bone for the first 20 sq cm or less and then use the add-on code of 11047 for each additional 20 sq cm.

Remember, when multiple wounds are debrided to the same depth, then the combined measurements of the debrided surface should be used to determine the appropriate code. The total surface area of each debrided wound must be documented separately, but each debridement may not be reported separately unless it is performed on different tissue types.

07:20 Wound Documentation Tips

As always, documentation is king. Documentation requirements are as follows –

• Describe the wound, including the size, the appearance, the drainage, the character, the presence of edema, infection and disease causing underlying problem or complication for the wound healing process.
• Describe the method of debridement (scalpel, nippers, scissors, curette), and which deepest layer of tissue was removed or debrided.
• A clear description of the tissue being cut away should be in the chart notes.
• Clear specifications of which dressings were applied, post-op care instructions provided, progress of the wound, and on follow-up visit notes or future plans.
• Description of wound improvement or measurable changes (for example- decrease in drainage, inflammation, necrotic tissue, pain, swelling, wound dimension changes, or declining improvement). It should include steps like oral antibiotics, further testing, biopsy of the wound, consultations requested for such vascular intervention, or podiatric consultation for bracing or off-loading anything done to address the new condition.

Generally, the prognosis for wound healing is individualized and depends on the specific type of wound, the underlying injury, and the overall health of the patient. In most cases, minor wounds like lacerations and abrasions usually heal on their own and do not require specialized medical care. However, depending on the severity and other complications of the wound, the prognosis for a perfect outcome reduces. The ultimate goal for all wounds is to have a proper healing that allows the injured part to function normally again.

I hope this helps, but always remember that documentation and a thorough knowledge of payer regulations and guidelines is critical to ensure accurate reimbursement for the procedures performed.

Thank you.