Healthcare Training: Beef Up Your Hospital-Based Wound Care Diagnosis Coding


As we’re focusing on wound care, we need to be sure that for ICD-9 coding we’re coding the condition for that encounter or the reason for the care following our outpatient guidelines. Remember, sometimes in our wound care areas we may call it rehabilitation. And that's kind of a marketing term. So don't get caught up on following the rehabilitation healthcare coding guidelines.

You always want to make sure that you have a physician order requisition for your services is absolutely required. And should be probably be something to keep in mind especially with the recovery audit contractors.

So, in your outpatient wound care area, one of the things that’s good to do not only because - from the compliance perspective, we need the physician order and to know what services this physician is asking for. But it's good from a legal perspective to standardize this form and even from a marketing perspective so it's identifiable to your own particular outpatient unit department that’s wound care specialist.

And so, we'd recommend you develop a form. Keep it one paged as much as you can. Make sure that you have appropriate information, you logo, where the diagnosis and multiple diagnosis can be listed. You'll need to be sure you routinely look to and update that.

If you choose to list some diagnosis on the form itself that are common to wound care, you can do that. And there is no problem with that. But also, leave a blank area with a line for other diagnosis that can be added by the physician. Again, in the outpatient area, we’re looking for this to be your first listed diagnosis which is your clinical condition and rational for that wound care services.

As we look at specific CMS rules, we can determine that we need to be looking at the ICD-9 CM coding conventions and specific guidelines for outpatient services. It may take one or two or more times before even a diagnosis is actually confirmed in some situations. So one time, you may have a diagnosis that you begin with and then after a time, we discover XYZ is really the condition.

Especially with wound care, it could be a situation where we didn’t - aren't sure that there is an infection or we’re not sure of a particular organism that’s part of that. And it will find out later in the multiple stage that do occur.

As we search for ICD-9 diagnosis codes, be sure you use terminology that will prompt you. And so, from the alphabetic index of the healthcare coding book you would go there first and then you would move to the tabular. And this will help eliminate any healthcare coding errors if you follow those steps. And in your encoder if you use terminology - and look at your encoder carefully, your computer software that’s going to lead you to the correct diagnosis.

In the documentation that you use to describe the condition, sometimes there's abbreviations used. Make sure these abbreviations are ones that are acceptable and your organization understood and understandable also - as well because we want to be sure we understand that the condition that’s going to be treated is going to meet medical necessity and so making sure documentation is very specific in describing that is going to be important to your coverage.

So as we move on to the diagnosis coding, the first listed diagnosis will be that condition - that problem that the patient is coming to the therapy for, what type of wound they have, if they have an infection. And then you will list of course any secondary diagnosis. It could be diabetes. It could be osteoporosis. It could be some other condition, peripheral vascular disease. And you can list those also as your diagnosis and have those coded.

Now, having said that as we talk about wound care, it's going to be important that your health information management hospital coding staff are very involved in the coding of these specific diagnosis because you could end up hitting a local coverage determination by the Medicare administrative contractors, the MACs. And you want to be sure that you have medical necessity coverage. And who knows better about the appropriate diagnosis coding specifics and healthcare guidelines is your HMI hospital coding staff.

We do not code in the outpatient setting any condition that is quantified by the terminology of probable, suspected, questionable, rule out or working diagnosis or similar terms. Now, on an inpatient medical record, yes, that's acceptable but not on an outpatient record. That's a different rule. So if you see this type of documentation, we need to go back to the physician and get a more specific information or get the signs and symptoms that may be related to this possible condition.

And look at what they say about outpatient therapy services, if they have specific guidance for wound care services, very, very important from medical necessity and compliance perspective. Because there's so many differences between FIs and MACs and that’s not something that’s been standardized across the United States, you have to look at your individual MAC or FI.

Now again, having that order is going to be very critical. And having the reason for the encounter will help justify your medical necessity for the treatment. Certainly, we get paid on the procedure codes themselves but remember, the first check and balance is to make sure the patient meets medical necessity and that’s based on the diagnosis.

And again, secondary diagnosis are going to be helpful to understand further the diagnostic requirements and the reasons for may be some additional tests that may be ordered via the wound care services. If you're a physician-based wound care department, this will be one of those areas where you'll often see additional orders for tests and services come out of the wound care therapy. And having additional secondary diagnosis will often support the medical necessity.

Also, in wound care units and departments that are physician-based, we often see physicians dictating history and physical assessments. Certainly, the first time the patient comes in, that initial H&P and assessment of that wound. And there you'll capture a lot more information about second diagnosis and second comorbidities that the patient may have. These two should be coded if they meet the secondary reportable diagnosis guidelines. And again, health information management will be key to help you with that.

As we look at the verbal order situations, what sometimes happens with therapists and nursing staff, therapists are part of that process too. One of the things that’s suggested is to make sure that we get a diagnosis. Sometimes the verbal order is just for the specific services and yet we don't have the rationale or the medical justification via the condition or code for the diagnosis - for the therapy that you're getting that verbal order for.

So sometimes reading back or asking, “What is the specific diagnosis Dr. (Smith) for that additional treatment that you're asking us to do?” That will avoid any claim denials that could result. And that will be better for your reimbursement. So that’s one thing that we've learned through wound care service lines as an area that could be improved upon and certainly something to discuss at your own department meetings.

Remember that if there is a diagnosis in an MD order, it is acceptable to code that diagnosis from the order. And that's okay to do. So it's important that the diagnosis be contained within that order.

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