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Showing posts tagged with: Home Care Coding

Educational Video: Coding Compliance Open Wound as a Primary Diagnosis

Susan Carmichael
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Educational Videos, ICD9-CM

Often we see the term "open wound" written as a diagnosis and 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 open wound can be used to refer to 10 or more types of wounds? Each of these wounds have different codes.  Because open would could mean a decubitus ulcer, venous stasis ulcer, a normally healing surgical wound, non-healing surgical wound, infected surgical wound, chronic skin ulcer, traumatic wound, burn or a diabetic ulcer; clarification would be needed.  Remember all those wounds have a different code. This stops the coding process until the nature, origin and location of the wound is on the body can change the code assigned.  Trauma wounds are caused by outside trauma, no surgery, such as lacerations, puncture, animal bites, avulsions or gunshots.  Superficial trauma  wounds are not full thickness wounds such as skin tears, abrasions or blisters.  A skin tear cannot be coded as a traumatic wound unless it is especially large, or the skin flap is gone. So when you're tempted to write "open wound" on that diagnosis line, please stop and think what kind of wound is this and where is it located and write that information as well.

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