Wounds, OASIS and Coding

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1 This handout includes slides from parts one and two of the Wounds, OASIS and Coding seminar Wounds, OASIS and Coding Lisa Selman-Holman JD, BSN, RN, CHCE, HCS-D, COS-C Selman-Holman & Associates, LLC This handout is intended for exclusive use by authorized viewers who have purchased this seminar from the.

2 Wounds, OASIS and Coding Part One Wounds, OASIS and Coding Part One Lisa Selman-Holman JD, BSN, RN, CHCE, HCS-D, COS-C Selman-Holman & Associates, LLC Objectives Discuss the differences between OASIS and coding wounds. Distinguish between the OASIS questions regarding wounds and complete assessment of the skin Reconcile coding of aftercare vs surgical wounds according to OASIS. Describe how to code types of wounds/skin lesions that are not described as wounds on OASIS. Describe how to code complicated wounds. 2 OASIS vs. Coding Rules OASIS is a Medicare requirement. OASIS is NOT a complete assessment. A complete assessment is part of standard practice forms the baseline of your patient, forms the basis of your POC. Coding according to the rules is a HIPAA requirement. 3 1

3 Wounds, OASIS and Coding Part One Wounds Not Wounds According to OASIS Mediports and central lines vs. peripheral lines Answering M0440 Answering M0482 Answering M0250 V58.81 fitting and adjustment of vascular catheter Some confusion when answering this question; NOT just central lines 4 Use of V58.81 Patient is getting solumedrol IV for exacerbation of MS. MO230 Multiple sclerosis MO240 V58.81 fitting and adj vasc cath MO240 V58.65 use of steroids Patient needs central line flushed TKO for periodic chemo MO230 V Use of V58.82 Intrathecal Subcutaneous insulin, baclofen,, pain What about surgical drains? Don t t forget M0250. How do you code the dressing changes on these vascular and non-vascular lines? 6 2

4 Wounds, OASIS and Coding Part One Ostomies Not a wound according to OASIS How to code V55s V44s Complications Ostomy points on OASIS 7 Yes on M0440 Trauma wounds Surgical wounds Stasis ulcers Pressure ulcers Other kinds of ulcers Partial thickness wounds Abscesses 8 Trauma Wounds ( ) 895) Open wound codes are meant only for traumatic injuries. Case Mix diagnoses (if M0440 is answered yes) Medically caused wounds should NEVER be included in this category. Includes: animal bites, avulsions, cuts, lacerations, puncture wounds, traumatic amputations 9 3

5 Wounds, OASIS and Coding Part One Trauma Wounds ( ) 897) Superficial injuries may be caused by trauma but should be coded as superficial injuries ( ) 919.9) PTWs Exception if there is something that complicates the superficial injury, e.g. diabetes 10 Trauma Wounds No V codes unless surgery was needed. If surgery, use V58.43 Aftercare following surgery for injury or trauma Is the wound still open? Do you get trauma points AND surgical wound points?? 11 Aftercare Surgery Injury/Trauma V58.43 Use for aftercare when patient has surgery after an injury or trauma Used with numeric codes Excludes V54.1x codes Use with other aftercare codes to specify aftercare 12 4

6 Wounds, OASIS and Coding Part One V58.43 Patient had a skin graft following widespread necrosis of his lower leg after a brown recluse spider bite. M0230 V58.43 Aftercare surgery for injury/trauma M Venomous bite M0240 V58.3 surgical dressings M0240 E905.1 Venomous bite as cause of toxic reaction M0245 Nothing 13 Trauma Wounds Code the complicated code if: Delayed healing Delayed treatment Foreign body Infection Use additional code to identify infection 14 Trauma Wounds Patient was on top of his house cleaning hurricane debris when he slipped and fell sustaining a injury to his head requiring surgery. Dressing changes and assessment. M0230 V58.43 Aftercare surgery injury and trauma M Open wound head M0240 V58.3 Surgical dressings M0240 E882 Fall from building M0245(a)

7 Wounds, OASIS and Coding Part One Trauma Wound Infections Patient was stabbed in the abdomen and the wound is now infected with E coli. MO Open wound abdomen, complicated MO E. coli, unspecified 16 Burns V code only if patient had surgery (V58.43) Code location of burn with severity of burn Code worst burn first Classify burns of the same local site but of different degrees to the subcategory identifying the highest degree recorded Then code total body of area burned Code a non-healing burn as an acute burn If burn is infected, follow with (post traumatic wound infection, NEC) 17 Patient has 3 rd degree burns on both arms and 2 nd and 3 rd degree burns on his face after the gasoline he was siphoning combusted. He has skin graft sites on both thighs. Burns 18 6

8 Wounds, OASIS and Coding Part One Burns V58.43 AC surgery trauma or injury rd degree face rd degree arms total surface/total surface 3 rd degree E894 Ignition of gasoline MO Contact Information Lisa Selman-Holman Selman-Holman & Associates, LLC or

9 Wounds, OASIS and Coding Part Two Lisa Selman-Holman JD, BSN, RN, CHCE, HCS-D, COS-C Selman-Holman & Associates, LLC Surgical Wounds No primary V codes for wounds unless there has been surgery on the wound. Coding a V code for aftercare does NOT mean that the wound is considered surgical according to OASIS. Stay with the original cause of the wound. 2 Surgical Wounds No open wound codes Effective 10/1/03 a V code is used for these patients Exception is if there is a complication, i.e. Dehiscence or infection If you have a complicated surgical wound, a V code is not appropriate 3 1

10 Surgical Wounds Code surgical wound complications as wound complications non-healing surgical wound 998.5x post-operative operative infection dehiscence disruption of internal operation wound dehiscence -- disruption of external operation wound Physician documentation required 996.xx complications of surgeries 4 Surgical Wound Infection Patient was admitted for wound care and observation and assessment of surgical wound infection caused by staph aureus. MO Other postoperative infection MO Staph aureus Do not code the infective organism if not known. NO V Codes for the aftercare!!! 5 Two additional issues Answering OASIS regarding the status of the wound Is the wound still complicated? 6 2

11 Attention to Surgical Dressings and Sutures V58.3 Only for surgical wounds!!! Only for routine surgical wounds!!! Part of aftercare is the focus of care REALLY dressing changes? 7 The V58.4x Codes V58.4 Other aftercare following surgery Codes from this subcategory should be used in conjunction with other aftercare codes to fully identify the reason for the aftercare encounter. V58.42 AC surgery neoplasm V58.43 AC surgery trauma and injury V58.44 AC transplant 8 Aftercare Following Organ Transplant V58.44 Aftercare following organ transplant Use additional code to identify the organ transplanted (V42.0-V42.9) V42.9) Do NOT also use V58.7x 9 3

12 Aftercare for Surgery for Neoplasm V58.42 Code with: Other aftercare codes to fully identify reason for aftercare Numeric codes Numeric code for type of neoplasm if undergoing continued treatment V10.xx Personal history of neoplasm if neoplasm is eradicated 10 V58.42 and the rule for neoplasms Patient had radical right mastectomy for breast Ca. Your focus of care is the surgical aftercare, including dressing changes and assessment. Pathology results have come back negative on presence of cancerous cells in breast but there is a small spot on the lung she will receive therapy for once surgical site heals. MO230 V58.42 Aftercare surgery neoplasm MO240 V58.3 surgical dressing changes MO240 V10.3 history breast cancer MO lung mets 11 Aftercare Surgery Various Systems-V58.71 V58.71-V58.78V58.78 V58.71 Sense organs V58.72 Nervous system V58.73 Circulatory system V58.74 Respiratory system V58.75 Teeth, mouth, GI V58.76 GU V58.77 Skin/subcutaneous V58.78 Musculoskeletal 12 4

13 Aftercare Surgery Various Systems-V58.71 V58.71-V58.78V58.78 Pay attention to: Numeric codes that are applicable Code numeric code only if the condition still exists Also code specific aftercare V Illustrative Example Amputation due to diabetic peripheral angiopathy (443.81) Amputation due to diabetic ulcer (707.1x) Amputation due to diabetic osteomyelitis (730.0x) 14 Answer these! Patient had surgery for a retinal detachment with a giant tear (361.03) Patient had surgery for an intracranial abscess (324.0) Patient had surgery for a pneumothorax (512.8) Patient had surgery to amputate a gangrenous leg (785.4) 15 5

14 Answer these! Patient had surgery for a retinal detachment with a giant tear (361.03) V58.71 Patient had surgery for an intracranial abscess (324.0) V58.72 Patient had surgery for a pneumothorax (512.8) V58.74 Patient had surgery to amputate a gangrenous leg (785.4) V Surgical Wounds Example: Patient had surgery due to a ruptured appendix. NO current infection but closing by secondary intention. Dressing changes. MO230 V58.75 Aftercare surgery of GI system MO240 V58.3 Attention to surgical dressings and sutures 17 Code This One! Patient is referred to home care following a muscle flap to a Stage IV pressure ulcer to the buttock. Wound care, including dressing changes. M0230 V58.77 AC surgery skin M0240 V58.3 dressing changes 18 6

15 Complication of a Surgery Patient had a joint replacement 1 month ago and now the site is infected and the artificial joint has to be removed. MO Infection and inflammation reaction due to internal joint prosthesis M0240 V43.6x for joint affected NO information about the causative organism, then don t t code it. 19 What else is a surgical wound? Debridement treatment, treatment, not a surgery Surgical drains yes, but not coded separately Abscess recent guidance from CMS 20 Cellulitis Cellulitis is normally caused when there is an opening in the skin. Code the wound, if any, then the cellulitis and then the organism if known. MO infected gastrostomy MO cellulitis abdominal wall MO staph aureus 21 7

16 Diabetic Ulcers 250.8x Diabetes with other specified manifestations Use for manifestations related to bone changes and diabetic ulcers Pressure ulcers are not a manifestation of diabetes Not described by M0 questions Not staged Points only if diabetes is in M0230 (or M0245a) 22 Diabetic Ulcers Always code diabetes first, then the ulcer Never code the ulcer first IF the physician states arterial diabetic ulcer IF the physician states neuropathic diabetic ulcer Otherwise use 8 as the 4 th digit 23 Diabetes 4 th digit 8 Your patient is an uncontrolled Type 2 diabetic on insulin with an ulcer on the toes on the left foot V

17 Arterial Ulcers Atherosclerosis of lower extremities , 707.1x No M0 question for identifying arterial ulcers 25 Stasis Ulcers Varicose veins (no add l code for ulcer) or Venous insufficiency followed by 707.1x Post phlebitic syndrome-459.1x, 707.1x Chronic venous hypertension-459.3x, 707.1x Do NOT stage! Often surrounded by stasis dermatitis (cellulitis) 26 Decubitus/Pressure Ulcers Decubitus, unspecified site Decubitus, elbow Decubitus, upper back Decubitus, lower back Decubitus, hip Decubitus, buttock Decubitus, ankle Decubitus, heel Decubitus, other site 27 9

18 Pressure Ulcers Answer OASIS questions Know official staging Even healed stage 3 and 4 ulcers Code all locations of the pressure ulcers. Don t t duplicate codes for ulcers in the same location. 28 Ulcers without the named causal conditions Ulcer related to cancer Patient has large draining and necrotic ulcer on left breast due to a breast cancer. Orders for wound care and assessment, MO chronic ulcer of other specified sites MO240 breast cancer 29 Web Sites OASISGuidance.pdf C_ARTINS.pdf C_QUICK1.pdf

19 Contact Information Lisa Selman-Holman Selman-Holman & Associates, LLC or

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