Coding for wound care: Is your EHR leading you astray?
The search function in your electronic health record (EHR) is not always your friend. Sometimes, the search term returns a diagnosis that seems to fit the patient’s condition but doesn’t. In other cases, the full description of the ICD-10 code may be missing, or you need to finish the patient’s chart and accept the EHR’s diagnosis without narrowing the results.
Selecting diagnosis codes for wounds is a case in point. Search “wound,” and the results may not describe the patient’s condition.
To help avoid this, remember these tips for three common types of wounds.
1. Use a code that starts with an “S” when the wound is a result of an accident or even something as simple as an insect bite. The documentation will describe the occurrence of the wound – when, where, and how it happened. The difficulty with these codes is that there are so many of them, so selecting a specific code can take a long time. If possible, avoid coding T14.8-, “other injury of unspecified body region,” or T14.9-, “injury, unspecified,” because these codes don’t describe the location or type of wound. These injury codes require a 7th character to indicate the episode of care.
2. A non-healing wound, such as an ulcer, is not coded with an injury code beginning with the letter S. Four common codes are L97-, “non-pressure ulcers”; L89-, “pressure ulcers”; I83-, “varicose veins with ulcers”; and I70.- “ulcers that are the result of atherosclerosis.” These types of wounds are not the result of an accident, and the documentation doesn’t describe a traumatic incident. These codes don’t require a 7th character to indicate the episode of care.
3. A third type of wound is a post-procedural wound. Although these wounds are more commonly seen in surgical practices, family physicians do sometimes see patients with wound disruption after a procedure. Category T81-, “complications of procedures,” covers many of these situations, including T81.3, “disruption of operation wound, not elsewhere classified.” These codes will require a 7th character.
The summaries below can help you select the right code when seeing a patient with a wound.
| Injuries |
• Code starts with the letter S. • Defined by location, type. • Avoid unspecified injury codes T14.8 and T14.9. • Don't use for non-traumatic, non-healing wounds • Requires a 7th character extender for episode of care. |
| Non-healing wounds (ulcers) |
• L97.- Non-pressure ulcer, defined by location and stage. • L89.- Pressure ulcer, defined by location and stage. • I83.- Varicose veins with ulceration, defined by location and symptoms. • I70.- Atherosclerosis with ulceration, defined by location. • Does not require a 7th character extender for episode of care. |
| Post-procedural complications |
• Wounds that are the result of a surgical procedure. • In category T81, complications of procedures not elsewhere classified. • T81.3 disruption of wound, not elsewhere classified. • Specific post-procedural complications defined elsewhere. • Requires a 7th character extender for episode of care. |
— Betsy Nicoletti, a Massachusetts-based coding and billing consultant
Disclaimer: The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. All comments are moderated and will be removed if they violate our Terms of Use.