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.

— Betsy Nicoletti, a Massachusetts-based coding and billing consultant