Coding Compliance Open Wounds as a Primary Diagnosis
Open Wound as a Primary Diagnosis
Often we see the term open wound used as a diagnosis, especially as a primary diagnosis. This is a vague term and should be avoided, because it will need clarification before it can be coded. Did you know that an open wound can be referred to 10 or more different types of wounds? And each one of these wounds has a different code or codes.
Some of these different wounds are:
- Decubitus Ulcer
- Diabetic Ulcer
- Venous Stasis Ulcer
- Normally Healing Surgical Wound
- Post-Op Wound Infection
- Dehisced Surgical Wound
- Traumatic Wound
- Burn
- Chronic Skin Ulcer
- Abscess
Each one of these requires as different code. This stops the coding process until the nature and the origin and the location of the wound can be identified. All these variables change the code or codes assigned.
Trauma wounds are caused by an outside trauma to the body and they include:
- Gun shots
- Avulsions
- Lacerations
- Punctures
- Not surgical
Surgical wounds are never coded as a traumatic wound. A superficial traumatic wound is not a full thickness wound and this includes:
- Skin tears
- Abrasions
- Blisters
Skin tear is not coded as a traumatic wound unless it is exceptionally large or the skin flap has been lost. Remember when you’re tempted to write open wound on that diagnosis line, please stop and consider specifically what kind of wound is this and where is its location, and put that information on the diagnosis line instead.
