One of the most difficult and misunderstood diagnostic coding types is that of a wound care clinic. Often managers lump these types of charts into clinic coding and expect productivity to be just as high. Ask any wound care coder and they’ll tell you that a wound care chart is one of the most confusing case types out there.
Most of the conditions treated in wound care clinic are chronic, nonhealing ulcers, yet the clinic is called wound care – not ulcer care - which is just the beginning of the confusion. Patients are often seen weekly, and the severity of their wounds (ulcers) can improve, deteriorate, or remain stagnant week to week. Many coders are unsure how to code these charts. What type of wound is being evaluated? How does the wound look this week? How, exactly, is the wound being treated?
Detailed documentation is the heart and soul of every medical record. Often, you’ll encounter physicians of different specialties working in wound care. Patients might see a vascular surgeon, an ED physician, a podiatrist, or even a nurse to help heal their wounds. But whose documentation should coders code from? The ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 tells us that coders may pull diagnoses from “…any health care practitioner who is legally accountable for establishing the patient’s diagnosis.” Clearly, physicians, physician’s assistants, and residents all fall into that category. Nurses can often fall into that category if they are nurse practitioners or nurses certified in wound care. Facilities should check their state licensing requirements to determine whose documentation can be reported. That information should be added that to the facility guidelines for coders to refer to when needed.
Knowing which provider’s documentation is fair game may be a start, but coders are often faced with a wound care summary upwards of 50 pages with physician documentation scattered throughout the chart. They’re forced to scroll through an entire chart to find that one progress note that is useable. It’s frustrating, but imperative that coders ensure they are abstracting only from documentation signed by the legally responsible party. But there is an exception; Guidelines allow coders to pull the depth of non-pressure ulcers and pressure ulcer stages from nonprovider clinicians as long as the provider has documented the actual ulcer. That means if the depth is not documented by the provider, the coder will need to scroll through all 50 pages to find that one instance in which the nurse mentions the depth.
What about those times when a patient is only being seen by a nurse for a dressing change? There are often instances when a dressing needs to be reapplied by a wound care nurse and the patient doesn’t need to see a physician. Shouldn’t a coder be able to code from nursing documentation in these cases? The answer is no. In these instances, be sure there is an order in the chart from the physician that includes the typical criteria necessary when writing an order.
To understand coding for wound care, coders must first hope the attending documented the cause of the ulcer. Was there a laceration that isn’t healing as quickly as it should? Did a surgical wound dehisce? Was there a burn? Maybe the patient just happened to look at their foot one day and noticed a breakdown of skin on their toe. Each mechanism of injury can lead to a different code. Add to that complicating secondary conditions like diabetes and peripheral vascular disease and suddenly a simple clinic visit turns into reporting multiple codes for a single wound.
Let’s talk about treatment next. Was there a debridement or just an Unna boot applied? What type of debridement was done? Maybe a wound vac was applied afterward. Maybe there was a debridement and then a graft application followed by a wound vac. What can be reported together? What are the measurements? Are there any measurements? Which ones matter? It becomes quickly apparent that wound care coding is extremely complicated.
For a coder to properly report the patient’s diagnostic codes, the physician must first accurately document that patient’s conditions. I’ll often suggest physicians visualize. A good working relationship between physicians and coders is instrumental for accurate coding and documentation. Most doctors, by nature, want to help people so encourage open dialogue with coders and ask questions. Invite a physician to do an in-service for your coding team and conversely, invite a coder to do an in-service for the providers. Both coders and clinicians could be pleasantly surprised at how much they could learn from each other.
Facilities need to do their part to set coders up to succeed as well. Here at Haugen Consulting Group, we recommend detailed guidelines be available to coders. Streamlining wound care progress notes and encouraging open dialogue between coders and clinicians will often lead to increased productivity and accuracy for all parties. It’s a win/win for everyone! I’ll be addressing these issues and so much more in my webinars: Wounded by Wound Care Part I and Part II. Join me!
Terri Reid, CCS, CCS-P, CDIP, AHIMA-Approved ICD-10-CM/PCS Trainer
Senior Coding Quality Auditor
Terri comes to Haugen Group with 20+ years of health information management experience in coding, auditing, and education. She began her career coding emergency room records and wound care records where she helped develop coding and E/M protocols and met with the providers to help them improve their documentation. Terri transitioned to an auditing role when she realized how much she enjoyed sharing her coding knowledge and experiences with other coders to help improve their skills and confidence. Terri brings her expertise in coding and auditing to the Haugen Consulting Group, having worked in previous roles leading and performing inpatient and outpatient coding audits. She is passionate about learning new medical technology and how the disease process affects illnesses.