Wound Care Documentation Case Study: Trauma

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. However, HMP Communications and the author 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.

When reviewing this case study, refer to the instructions given in the case study published in the January/February 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 No. 1: 40-Year-Old Male 1st Visit: Patient presents for an initial visit with a laceration of the right great toe with nail bed damage. No foreign body is noted. Patient was injured after accidentally hitting his toe with a garden edger at home. Patient was wearing sandals. 2nd Visit: Patient returns for a follow-up visit for suture removal.

Case No. 2: 46-Year-Old Female Woman presents with 48-hour-old crush injury to right hallux. No significant past medical history.

Using the code tables, as well as your ICD-10 codebook, properly code the diagnoses for each 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.