Medical necessity denials traditionally focus on high-dollar MS-DRGs, such as those for hip and knee replacements; other MS-DRGs may also soon become targets. We have identified some of the challenges in Wound Care Medical Coding.

Healthcare providers are likely to perform accurate medical coding under ICD-10 and that is when having an outsourcing medical billing coding partner like MBC will be beneficial.

Documentation lacks the clinical substance necessary to support medical necessity, and it doesn’t capture a physician’s clinical judgment and medical decision-making for performing the procedure. Doctors have been conditioned to document excisional debridement, but if you look at what they need for their own payment, they need to do a lot more than that. To do wound care medical coding for inpatients frequently lacks sufficient documentation.

It has become crucial than ever for wound care providers to make sure that they are doing coding to the utmost specificity and following all the ICD-10 guidelines. While it is still unclear exactly how forgiving CMS was under this grace period, it is possible that some things that were working in the first year of ICD-10 may not continue to be satisfactory.

The Challenges With Wound Care Medical Coding

1. There is misperception with coding and billing is that if there is a code for a procedure or product, the insurance plan will pay it. This is not necessarily the case. Having a code does not directly translate to the coverage for the procedure, therefore, it becomes imperative to know the rules under which you must operate is a must.
2. Another common error is not using the add-on codes properly. If removing over 20 cm2 of tissue at a certain depth, he says to use the base code and the add-on code. For example, if removing 28 cm2 of subcutaneous tissue, he notes the coding would be both 11042 and 11045.
3. Coders are often too cautious when assigning a present on admission (POA) indicator for pressure ulcers, especially when the provider does not document the ulcer until several days after inpatient admission. If signs or symptoms are POA, coders can and should report an ulcer as POA. A query may be necessary without documentation of signs or symptoms.
4. ICD-10-PCS distinguishes between excisional and non-excisional debridement. The ICD-10-PCS root operations excision and extraction denote excisional debridement and non-excisional debridement, respectively. This doesn’t mean that physicians must use the term extraction, but if documentation shows that the tissue was pulled or stripped away, rather than cut, the debridement is an extraction.ICD-10 will require coders to capture laterality and more specific anatomic wound locations.
5. There have been disagreements, and debates between what’s considered to be a “wound” versus an “ulcer.” Sometimes, ICD-10 is almost like its own language, and this is one of those situations. Be aware of ICD-10 semantic, that medical staff often make mistakes. While many clinicians may interchange the terms “ulcer” and “wound” as if they are substitutes, they are not other words when it comes to ICD-10 medical coding.
6. Physicians respond to the documents during their administrative hours. Because manual physicians query delay in medical coding and billing and don’t have a great response rate from physicians, providers should consider automated physician queries.
7. Understand the difference between wound debridement, open fracture debridement, and active wound care coding. Also; there are errors in coding correctly when skin grafting/replacement is involved.

The billing of wound care services usually involves a thorough evaluation of the patient’s medical record for the wound, including wound dimensions, chronic diseases which includes diabetes, chronic ulcers, quadriplegia, etc. procedures offered to manage the wound, follow-up, first visit, photographs of the wound, and wound progress. To have MBC as your wound care medical billing and coding partner can help overcome the above-mentioned challenges.