If you base your code selection for a surgical wound on the clinician’s response to M1342 (Status of Most Problematic Surgical Wound that is Observable), you could easily find yourself unintentionally upcoding the claim.
Example: Your patient comes to home health for aftercare following gallbladder removal surgery three days prior. The assessing nurse marked M1342 as “3 (Not Healing)” and documents that the stitched wound is red and swollen.
If you assign T81.4- (Infection following a procedure) based on the assessing nurse’s documentation and M1342 response instead of the code for routine surgical aftercare, that’s upcoding. In this scenario, based on the given information, Z48.815 (Encounter for surgical aftercare following surgery on the digestive system) is the correct code.
Caution: T81.4- is eligible for up to 17 case-mix points while Z48.815 earns zero. assigning the former without further confirmation from the physician that the surgical wound is infected is risky.
Key: A non-dehisced surgical wound with an approximated incision (edges have been pulled back together and held in place by something like sutures, staples or glue) is healing by primary intention. Because these wounds do not granulate, there are only two possible answers to M1342 in these cases — “0” for newly epithelialized or “3” for not healing, according to the OASIS guidance manual.
When these wounds don’t yet show signs of being newly epithelized, they must be marked as “Not healing.” But that doesn’t mean that the wound is infected or otherwise complicated.