If a patient's surgical wound may be complicated, but the coding need not be. Heed these three simple steps to ensure the accurately reporting all the care your agency provides.
1. Know when it is complicated:
A complication is a problem that takes place during the healing process of the initial surgical procedure which impacts healing negatively, says Judy Adams, RN, BSN, HCS-D, COS-C, president and CEO of Adams Home Care Consulting in Chapel Hill, N.C. For instance, an infected surgical wound is thought of as complicated.
Tip: According to Adam, there is no time limit to coding a surgical wound as complicated. Even if the complication takes place sometime after surgery, you can still code for the wound as complicated.
2. Get to the right code
See under "complication" in the alphabetic index of your coding manual to start your search, says Adams. After this, verify the code in the tabular list, and follow the directions for any additional codes. Adam points out, there're many complication codes for wounds of all types in chapter 17 at 996.xx (Complications peculiar to certain specified procedures), 997.6x (Amputation stump complication), 998.3x (Disruption of wound), and 998.5x (Postoperative infection) for postoperative wound complications. Moreover, look to 998.83 (Non-healing surgical wound) and 997.xx (Complications affecting specified body systems, not elsewhere classified).
3. Do not turn to aftercare:
Although your agency is providing care post-surgery, you should not use an aftercare V code when the surgical wound is complicated. In this case, the complication code trumps the aftercare V code in this case. As per coding guidelines, "The aftercare V code shouldn't be used if treatment is directed at a present, acute disease or injury. The diagnosis code should be used in these cases."
But you may once in a while find an exception to this rule. For instance, if your agency is caring for an infected surgical wound which requires IV care, you would make use of the right complication codes to report the wound, but you could still list V58.81 (Fitting and adjustment of vascular catheter) and V58.62 (Long-term (current use of antibiotics).
Another instance: Adams says that instructional notes at 996.4x (Mechanical complication of internal orthopedic device, implant, and graft) and 996.66 (Infection and inflammatory reaction due to internal joint prosthesis) counsels coders to "use additional code to identify the prosthetic joint with mechanical complication or infection (V43.60-V43.69)."
Take a look at these two coding scenarios
A patient of yours has come home after a coronary artery bypass graft (CABG) for coronary atherosclerosis (CAD) of his native artery. He needs constant observation and assessment of the surgical incision on his leg with three areas of incisional separation but with no signs of infection. He's a bit weak but does not have chest pain anymore. The patient has diabetes with fasting blood sugar of 109 and diabetic peripheral angiopathy. He also has benign prostatic hyperplasia with urinary retention and frequent urinary tract infections and will be planned for a transurethral resection of the prostrate pretty soon. Your orders are meant for skilled nursing and physical therapy coding.
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