Wound Care Documentation Case Study: Diabetic Conditions

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure information accuracy. However, HMP Communications and the authors do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.

  This year will bring exciting changes to the industry, including the implementation of ICD-10-CM on Oct. 1. Many wound care providers and program directors have been doing quite a bit of work preparing for the new coding system (which was originally intended for 2014), while some may have put this important transition on a back burner. To assist those in preparing for the amount of specificity that will be required for documentation under ICD-10 coding, Today’s Wound Clinic provided a series of ICD-10 documentation improvement grids for wound care-specific issues throughout 2014.These grids are meant to provide practitioners with reference guides to ensure understanding of new codes and coding rules. In addition, practitioners have been encouraged to audit their own documentation with the use of the grids to determine opportunities for improvement of documentation practices.

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
RELATED CONTENT
ICD-10-CM Diagnosis Coding Documentation Tips for Diabetes Mellitus
Identifying New ICD-10-CM “Buzzwords” in Diabetes Terminology
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

  Hopefully, readers have had the opportunity to review documentation utilizing these tools by now. As an additional preparation tool throughout 2015, we will provide sample cases demonstrating the principles conveyed over the past year. When reviewing these cases, use the documentation tool created for each topic to enhance learning. These tools can be accessed online at www.todayswoundclinic.com/category/section/icd-10. For the first case study, we’ll focus on documentation principles for diabetes-related conditions.

  This is the first of six case studies that will be provided through August.

Documentation Case Study: Diabetic Conditions

(Note: Code ICD-10 diagnoses information only.)

   “Margaret A.” is a patient at the wound care clinic for evaluation and treatment of a diabetic ulcer on the heel of the left foot. She lives with diabetes type 1 and has a documented long-term use of insulin. Her endocrinologist has requested that the clinic assist in the monitoring of her blood sugar, as she has been uncontrolled for the past two weeks. Current fingerstick readings still indicate uncontrolled levels. The patient is also experiencing diabetic neuropathy and diabetic angiopathy. The ulcer appears to have fat layer exposed.

  Plan: Debride the wound and apply moist wound healing dressings.

  Use the coding table and the ICD-10 coding book to properly code the diagnoses for this case.

  For answers, click here.

Donna Cartwright is certified as an American Health Information Management Association ICD-10-CM trainer and senior director of strategic reimbursement for Integra LifeSciences Corporation, Plainsboro, NJ. She may be reached at 609-936-2265 or donna.cartwright@integralife.com for questions or consultation.