Wound Care Documentation Case Study: Complications of a Graft

  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 information accuracy lies with the reader.

  When reviewing this case study, refer to the instructions given in the case study that was published in the January/February 2015 issue of Today’s Wound Clinic (as well as the series of ICD-10 Diagnosis Coding Documentation Tips that were regularly provided between October 2013 and December 2014) in an effort to evaluate your documentation practices. Remember: We are only working with the diagnosis codes in these particular case studies to reinforce the importance of documentation specificity, as that is a key element for data accuracy. The appropriate diagnosis code is also necessary for determining medical necessity.

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Case Study: Complications of a Graft

by Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA
(Note: Code ICD-10 diagnoses information only.)

  The patient is a 62-year-old white male who lives with several large ulcers of the left leg that are classified as venous ulcers due to associated edema as well as fibrosis and varicose veins. All other lower (left) leg ulcers have dramatically improved with aggressive compression bandaging. There is a large area of breakdown of a previously applied tissue-based product on the posterior aspect of the lower left thigh measuring 2 cm² x 2 cm.² A biopsy was performed that was negative, but the ulcer has failed to respond to conservative management. The plan for this patient is to re-excise the wound and apply a different tissue-based product. Other factors impacting this patient are hypertensive heart disease and a previous below-knee amputation. The plan for this encounter was discussed with the patient, who has agreed to the procedure to be done in the wound clinic.

  Using the code table and your ICD-10 codebook, properly code the diagnoses for this case.

  For answers, click here.

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