Commonly caused by falls or accidents with sharp objects or tools, open wounds refer to injuries that involve an external or internal break in body tissue, mainly the skin. These wounds can be complicated or uncomplicated. For uncomplicated wounds, medical documentation and the diagnostic statement must specify delayed healing or treatment, the presence of a foreign body or infection. Physicians treating such wound conditions must document the diagnosis and medical procedures with accurate medical codes. Before preparing and submitting claims, care providers must determine whether the wound treatment they are claiming reimbursement for is covered by the insurance coverage policy framed by Medicare and Medicaid (CMS), which requires familiarity not just with medical necessities but also with insurance coverage. Medical coding outsourcing is worth considering, as timely and accurate coding and submission of medical services provided is critical for on-time reimbursement.
Common open wound types are:
- Abrasion – It often occurs when the skin rubs or scrapes against a rough or hard surface. This wound comes with minor to no bleeding, with some pain, but needs to be scrubbed and cleaned to avoid infection.
- Laceration – This wound refers to a deep cut or tearing of the skin, mainly from accidents with knives, tools, and machinery. Lacerations involving blood vessels and muscle bundles should be identified by anatomical location.
- Punctures: A puncture is a small rounded wound caused by long, pointy objects such as a nail, needle, or ice pick. Even with minor bleeding, these wounds can be deep enough to damage internal organs.
A skin tear may also be coded as a traumatic wound if it is exceptionally large or skin flap has been lost. Medicare expects that wound care may be necessary for surgical wounds that must be left open to heal by secondary intention, infected open wounds induced by trauma or surgery, wounds with biofilm, wounds associated with complicating autoimmune, metabolic, and vascular or pressure factors and open or closed wounds complicated by necrotic tissue and/or eschar.
ICD-10-CM Coding for Open Wounds
Diagnosis codes for open wounds are categorized on the basis of anatomic location on the body, laterality, encounter as well as the type of wound.
Codes for open wounds are also found consistently across the body sites. The types of open wounds classified in ICD-10-CM are laceration without foreign body, laceration with foreign body, puncture wound without foreign body, puncture wound with foreign body, open bite, and unspecified open wound.
For instance,
- S81.812A Laceration without foreign body, right lower leg, initial encounter
- S61.431A Puncture wound without foreign body of right hand, initial encounter
- S61.432A Puncture wound without foreign body of left hand, initial encounter
- W54.0XXA Bitten by dog, initial encounter
In ICD-10-CM, injuries to all areas have been arranged into diverse category code ranges such as
- S00 to S09 – head
- S10 to S19 – neck
- S20 to S29 – thorax
- S30 to S39 – abdomen, lower back, lumbar spine, pelvis, and external genitals
- S40 to S49 – shoulder and upper arm
- S50 to S59 – elbow and forearm
- S60 to S69 – wrist and hand
- S70 to S79 – hip and thigh
- S80 to S89 – knee and lower leg
- S90 to S99 – ankle and foot
- T07 – unspecified multiple injuries and
- T14 – unspecified body region
Each category code includes more specific codes to document the wound better. The fourth digit indicates whether the wound is simple or complicated or whether there is tendon involvement.
For example, more specific codes for open wound of the thigh are –
- S71.10 – Unspecified open wound of thigh
- S71.101 – Unspecified open wound, right thigh
- S71.102 – Unspecified open wound, left thigh
- S71.109 – Unspecified open wound, unspecified thigh
- S71.11 – Laceration without foreign body of thigh
- S71.111 – Laceration without foreign body, right thigh
- S71.112 – Laceration without foreign body, left thigh
- S71.119 – Laceration without foreign body, unspecified thigh
- S71.12 – Laceration with foreign body of thigh
- S71.121 – Laceration with foreign body, right thigh
- S71.122 – Laceration with foreign body, left thigh
- S71.129 – Laceration with foreign body, unspecified thigh
- S71.13 – Puncture wound without foreign body of thigh
- S71.131 – Puncture wound without foreign body, right thigh
- S71.132 – Puncture wound without foreign body, left thigh
- S71.139 – Puncture wound without foreign body, unspecified thigh
- S71.14 – Puncture wound with foreign body of thigh
- S71.141 – Puncture wound with foreign body, right thigh
- S71.142 – Puncture wound with foreign body, left thigh
- S71.149 – Puncture wound with foreign body, unspecified thigh
- S71.15 – Open bite of thigh
- S71.151 – Open bite, right thigh
- S71.152 – Open bite, left thigh
- S71.159 – Open bite, unspecified thigh
CPT Coding for Wound Care Documentation
Debridement or other treatment services can be billed when an extensive cleaning of a wound is needed prior to the application of primary dressings or skin substitutes placed over or onto a wound that is attached with secondary dressings.
- Use CPT codes 97597 and/or CPT 97598 to bill for recurrent wound debridements when they are medically reasonable and necessary. These codes are also considered “sometimes” as therapy codes.
- Payment for low frequency, non-contact, non-thermal ultrasound treatment (97610) is included in the payment for the treatment of the same wound with other active wound care management CPT codes (97597-97606) or wound debridement CPT codes (11042-11047, 97597, 97598). Low frequency, non-contact, non-thermal ultrasound treatments would be separately billable if other active wound management and/or wound debridement is not performed.
- Debridement of a wound, performed before the application of a topical or local anesthesia is billed with CPT codes 11042 – 11047. These CPT codes cannot be reported in conjunction with 97597-97602 for the same wound.
To meet all coding and billing requirements, physicians or clinics providing wound care treatments can consider choosing a medical billing company, experienced in handling the entire cycle of activities ranging from determining insurance eligibility to submitting claims and performing routine follow-ups.
Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.