Documenting and Coding Different Types of Wounds – A Detailed Overview

Wounds that damage the skin are of different types and include – abrasions, lacerations, scratches, rupture injuries, punctures, and penetrating wounds. They often occur due to accidents or falls (with sharp objects or tools). However, surgeries, stitches, sutures or even complications related to other conditions (like diabetes) can also cause certain types of wounds. Minor wounds generally are not serious, but it is important to clean them. On the other hand, serious and deep infected wounds may require immediate medical attention to prevent the chances of infection and loss of function, due to damage to the underlying structures like bone, muscle, tendon, arteries and nerves.

Regardless of the type of wounds and how they occur, it is important to receive proper wound care with effective, immediate treatment and ongoing diligence. In fact, wound care covers wound treatment as well as evaluation and management (E/M). If left untreated, wounds can become chronic and significantly affect the individual’s quality of life and prevent him/her from doing things they enjoy. Physicians treating different types of wound conditions must correctly document the diagnosis and other medical procedures performed using the correct medical codes.
Outsourcing medical billing services is an option worth considering, as timely and accurate coding and submission of medical services provided is critical for on-time reimbursement.

As per the Adroit Market Research report (on Global Wound Care Market), the global wound care market is projected to reach an approximate value of USD 25.1 billion by the end of 2025, growing at a CAGR of 3.7%. A significant increase in the prevalence of chronic wounds along with a rapidly growing geriatric population across the globe is one of the major factors that drive the global wound care market. Increasingly prevalent sedentary lifestyle, unhealthy food habits, chronic diseases (such as obesity and diabetes) and rapidly growing geriatric population susceptible to these diseases are the top factors expected to drive the global wound care market.

Types of Wounds – Top Causes and Symptoms

As mentioned earlier, wounds occur when the skin is broken or damaged due to an injury. Injuries may occur as a result of a combination of mechanical, chemical or thermal sources. The skin can get damaged in a variety of ways depending upon the mechanism of injury like inflammation, superficial (on the surface) wounds and abrasions, deep abrasions (cuts or lacerations), pressure sores(bed sores) and human and animal bites. Severe pain, swelling and bleeding are the most common symptoms of wounds. The amount and severity of pain may depend on the location and the mechanism of injury.

As there are different types of wounds, having a correct understanding about the same is an important aspect in treating wounds. Common types of wounds include –

• Acute Wounds – These types of wounds occur due to a disruption of the skin or underlying soft tissue, and has a well-organized healing process with predictable tissue repair. Commonly occurring in muscles, bones, and internal organs, these types of wounds include – lacerations, bruises and rupture of blood vessels within the skin as a result of direct trauma.
• Chronic Wounds – When acute wounds do not heal properly, they can become chronic wounds (particularly dangerous for elderly people). When an acute wound transforms into a chronic wound, it can come with severe side effects, such as infection, ulcers and inflammation. All chronic wounds begin as acute wounds and generally include – vascular ulcers, pressure ulcers and diabetic ulcers.
• Open Wounds – 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. Common open wound types include – lacerations, abrasions and punctures.
• Closed Wounds – This is a type of wound with intact skin, and underlying tissue that does not get directly exposed to the outside environment. Common wound types include – contusions, hematomas and crash injuries.

Wound Care – Diagnosis and Treatment

Diagnosis of wounds may begin with a detailed physical examination wherein physicians may inspect the type of wound, its severity and associated symptoms. Imaging tests like X-ray (to look for broken bones or fractures and other foreign objects that may have embedded in the laceration), fluoroscopy (help find foreign bodies) and ultrasound (to assist in diagnosis of foreign bodies in the wound) may be performed to analyze the root cause of the condition and determine the correct treatment options. By performing these tests physicians will check whether there is an associated injury with the wound. Understanding the previous history and the circumstances of the injury is crucial for determining the correct treatment and other after care required.

Most types of wounds can be easily cared for at home. Abrasions and lacerations can be easily cleaned and bacterial ointment can be applied and then covered with a bandage. In any case, if bleeding occurs, it can be easily controlled with direct pressure to the wound and if possible, elevating the bleeding site above the level of the heart. Treatment for different types of wounds or skin damage includes – assessment, management, and cleansing of the wound, simple debridement; and removal and reapplication of the wound dressings.

Treatment for different types of wounds may depend on several factors like – type of injury, the extent, and circumstances of the lesions, time frame from when the initial injury occurred and when the medical care is sought. In some cases, people with diabetes, poor circulation, on dialysis, or taking medications that can compromise the immune system may be at higher risk of suffering infections. Treatment involves – sutures (stitches) for wounds and prescription antibiotics. As part of the treatment, the health care professional will clean the wound and then check specific areas for foreign bodies or underlying structures that may have been damaged prior to closing the wound with sutures, staples. Antibiotics may also be prescribed if underlying structures like tendons or bones are involved. For traumatic injuries (chronic wounds and ulcers), surgical intervention including debridement may be necessary.

Billing and Coding for Different Types of Wounds

Active wound care procedures involve removing devitalized and/or necrotic tissue to promote healing. Therefore, it is important to have an in-depth understanding of skin anatomy, the codes for wound care services, and related documentation requirements for reporting wound care services accurately. Healthcare providers while treating different types of wounds must correctly document the related symptoms and causes. Billing and coding service offered by reputable medical billing companies could ensure accuracy in billing and thereby appropriate reimbursement.

ICD-10-CM Coding for Open Wounds

Diagnosis codes for open wounds are grouped on the basis of anatomic location on the body, laterality, encounter as well as the type of wound. Codes for open wounds are 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, more specific codes for open wound of the knee and lower leg include –

• S81.01 Laceration without foreign body of knee
• S81.011 Laceration without foreign body, right knee
• S81.012 Laceration without foreign body, left knee
• S81.019 Laceration without foreign body, unspecified knee
• S81.02 Laceration with foreign body of knee
• S81.021 Laceration with foreign body, right knee
• S81.022 Laceration with foreign body, left knee
• S81.029 Laceration with foreign body, unspecified knee
• S81.03 Puncture wound without foreign body of knee
• S81.031 Puncture wound without foreign body, right knee
• S81.032 Puncture wound without foreign body, left knee
• S81.039 Puncture wound without foreign body, unspecified knee
• S81.04 Puncture wound with foreign body of knee
• S81.041 Puncture wound with foreign body, right knee
• S81.042 Puncture wound with foreign body, left knee
• S81.049 Puncture wound with foreign body, unspecified knee
• S81.05 Open bite of knee
• S81.051 Open bite, right knee
• S81.052 Open bite, left knee
• S81.059 Open bite, unspecified knee
• S81.8 Open wound of lower leg
• S81.80 Unspecified open wound of lower leg
• S81.81 Laceration without foreign body of lower leg
• S81.82 Laceration with foreign body of lower leg
• S81.83 Puncture wound without foreign body of lower leg
• S81.84 Puncture wound with foreign body of lower leg
• S81.85 Open bite of lower leg

In ICD-10-CM, injuries to all body areas have been arranged into diverse category code ranges such as –

• S00-S09 Injuries to the head
• S10-S19 Injuries to the neck
• S20-S29 Injuries to the thorax
• S30-S39 Injuries to the abdomen, lower back, lumbar spine, pelvis and external genitals
• S40-S49 Injuries to the shoulder and upper arm
• S50-S59 Injuries to the elbow and forearm
• S60-S69 Injuries to the wrist, hand and fingers
• S70-S79 Injuries to the hip and thigh
• S80-S89 Injuries to the knee and lower leg
• S90-S99 Injuries to the ankle and foot
• T07 Injuries involving multiple body regions
• T14 Injury of unspecified body region

CPT Codes for Wound Care

Wound debridement is a medical procedure that removes infected, damaged, or dead tissue to promote healing. Debridement or other treatment services can be billed when 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.

Wounds Not Involving Subcutaneous Tissue

• 97597 Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (e.g. fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less
• +97598 each additional 20 sq cm, or part thereof (these should be list separately in addition to code for primary procedure)

Debridement

Wounds Involving Subcutaneous Tissue

• 11042 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed) first 20 sq cm or less
• +11045 each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

Wounds Involving Muscle and/or Fascia

• 11043 Debridement, muscle and/or fascia (includes epidermis and dermis and subcutaneous tissue, if performed); first 20 sq cm or less
• +11046 each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

Wounds Involving Bone

• 11044 Debridement, bone, (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less
• +11047 each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

When multiple wounds are debrided to the same depth, then the combined measurements of the debrided surface should be used to determine the appropriate code(s). The total surface area of each debrided wound must be documented separately. But, each debridement may not be reported separately, unless performed on different tissue types.

Documentation Requirements

• Describe the wound, including size (length x width); depth; total sq cm; appearance; drainage; undermining; peri-wound character; presence of edema, infection, and disease causing underlying problems or complication(s) for the wound healing process.
• Describe the method of debridement (scalpel, nippers, scissors, curette), and which deepest layer of tissue was removed or debrided (fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm; subcutaneous tissue; muscle and/or bone).
• Clear description of the tissue being cut away in the chart notes.
• Clear specification of which dressings were applied, post-op care instructions provided, progress of the wound, and on follow-up visit notes, future plans.
• Description of wound improvement or measurable changes (for example – decrease in drainage, inflammation, necrotic tissue or slough, pain, swelling, wound dimension changes, or declining improvement). It should include steps like oral antibiotics, further testing, biopsy of the wound, consultations requested for vascular intervention, or podiatric consultation for bracing or off-loading – done to address the new condition.

Generally, the prognosis for wound healing is individualized and depends on the specific type of wound, the underlying injury, and the overall health of the patient. In most cases, minor wounds like lacerations and abrasions heal on their own and do not require specialized medical care. However, depending on the severity and other complications of the wound, the prognosis for a perfect outcome reduces. The ultimate goal for all wounds is to have a proper healing process that allows the injured part to function normally.

Treating and managing patients with different types of wounds can be quite challenging for physicians. Outsourcing medical billing and coding tasks is a practical option for physicians to ensure accurate clinical documentation of wound care as well as appropriate care for their patients.