May 2005

Wound Care Identity Crisis and Coding Problems

Do you continue to have problems with your Outcomes Based Quality Monitoring (OBQM) and Outcomes Based Quality Improvement (OBQI) reports and incorrect reimbursement related to wound care? Let’s see if we can make some sense out of these different MO questions and begin with identifying wounds.

When PPS was established, certain categories of wounds were identified for increased reimbursement. To get this reimbursement, clinicians and coding staff must understand the etiology of the wound that is being cared for.

Let’s begin with diabetic ulcers; a clinical diagnosis needs a manifestation code along with it to follow coding regulations. Using the code 250.8x in MO230 identifies the wound you are caring for as a diabetic ulcer, and 707.xx in MO240 identifies where the ulcer is. In this case you are getting 17 clinical points in the clinical domain. You would answer MO440 as a yes – the patient has a skin lesion or wound, but you would not classify that same wound as pressure, stasis or surgical. This would be considered “double dipping”. Physicians often refer to these wounds as ulcers, and there may be a need to clarify with the physician the etiology of the wound or obtain a History and Physical to support the diagnosis.

Clinicians often struggle with correctly identifying arterial ulcers in comparison to venous ulcers (stasis ulcers). Giving clinicians a comparison chart of the differences in classifying diabetic, stasis and arterial ulcers can be a tremendous assistance to the field staff as they try to determine the etiology of the wound, especially when there is no information from the referral.

For example, when comparing the 3 types of ulcers, we could look at location. Venous ulcers are usually found on the medial aspect of the leg superior to medial malleolus (gaiter area). Arterial ulcers are found on any part of the leg, commonly below the ankle. Diabetic ulcers are usually found on any part of the leg, commonly below the ankle and on the foot.

Pain in a venous ulcer may be present when the extremity is in the dependent position. Arterial ulcer pain is usually present at night or when the leg is elevated, due to lack of blood supply. In the case of a diabetic ulcer, there may be no pain if the patient also suffers from neuropathy or paresthesia. Wound edges in a venous ulcer are usually shallow with diffuse edges, and the wound is usually large with an irregular border and shape. An arterial ulcer usually has a “cliff” edge similar to undermining. The wound is usually small and round, with smooth edges and a “punched-out” appearance. A diabetic ulcer may also have a “cliff” edge, is often very small and is usually round. The surrounding callus may have tracking or undermining.

Since we have talked about the ICD-9 coding for the diabetic ulcers, let’s discuss venous ulcers. When coding any type of ulcers from the 707.xx chronic ulcers, there are many coding rules that go along with this code. Again, it is important the clinician understands the etiology of the wound. There are code first rules for any causal condition of the ulcer first, which is what you would place in MO230. The actual ulcer would then be coded in MO240. No clinical points are given for this category of ulcer as to how you would answer MO468, which leads to MO476, where the clinical points are assigned depending on the status of the most problematic (observable) stasis ulcer.

Arterial ulcers are usually chronic ulcers and, due to lack of blood supply, are difficult to heal. Again, no clinical points are assigned in the diagnosis area, and the only MO item that identifies the presence of the arterial ulcer is MO440. These wounds are not pressure, stasis or surgical.

Pressure ulcers are assigned clinical points in MO450, the current number of pressure ulcers at each stage and at the MO460 stage, the most problematic (observable) pressure ulcer. The ICD-9 coding for this group of pressure ulcers begins with 707.0x where the fifth digit was added October 1, 2004, to identify the location of the pressure ulcer.

Clinicians must not only be able to identify the types of wounds they are assessing, but also the stage at which the wound is currently healing. This is found in the WOCN guidelines that were released to provide consistent definitions for the answers to the OASIS assessment when identifying at what stage the wounds are healing and if they are healing. Clinicians and supervisors must be familiar with the document “WOCN guidelines on OASIS skin and wound.” It is available to download in a pdf file at www.wocn.org.

Lastly, let’s discuss the use of open wound codes that come from the ICD-9 chapter titled “Injury and Poisoning”. In order to use a code from this chapter, the wound must have been caused by injury or trauma. I recommend the use of an E code to explain how the injury occurred. If a surgical wound has a dehiscence, it does not become an open wound. You cannot obtain the 21 clinical points assigned to the category of burns and trauma because you have a non-healing surgical wound. The wound was not caused by injury or trauma, it was caused by a surgical procedure and you now have a complication of surgery to go along with your non-healing surgical wound.

Identifying wounds correctly will assist your clinicians in getting the correct
ICD-9 codes assigned to MO230 and MO240. They will also be able to correctly identify not only the type of wound, but also how the wound is healing. This will help you obtain the correct reimbursement for the care you provide to your wound care patients.

Julie S. Peterson, RN, BSN HCS-D
Alegent Health Home Health Services

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