Identify the focus of care when you’re coding for wounds and ensure that you understand the guidelines regarding when it is not appropriate to assign a Z48.- code as primary — in particular Z48.00 (Encounter for change or removal of nonsurgical wound dressing) and Z48.01 (Encounter for change or removal of surgical wound dressing).
When the 2020 home health PPS final rule came out, there was a lack of clear understanding of how and when to use these codes, and coding experts frequently see issues with these codes that can lead to upcoding.
Avoid upcoding
To properly code for these dressing changes, refer to the 2020 HH PPS Final Rule issued in October 2019 regarding PDGM. The Final Rule contains scenarios that spell out how the classification of specific codes to primary grouping was done. The rule also offers specifics about when to assign Z48.01 specifically and other wound-related codes. Specific scenarios outline when to choose aftercare and when to select Z48.01 so avoid upcoding.
Do’s for proper use
Z48.01 is an acceptable primary code to indicate the routine wound care of a surgical wound. However, you must consider whether the wound care provided represents the focus of care for that episode before assigning the Z48.01.
Surgical aftercare of incisions/surgical wounds can vary greatly from the need for complex, frequent wound vac dressing changes to teaching a patient to cover an incision with a simple ABD that may only be applied for a few days. Just because a surgical wound is present, doesn’t mean it’s the focus of care.
When the care of the surgical wound does represent the focus of care, place the code before the aftercare following surgery code to indicate that the wound care is the focus of care. It is also acceptable to put Z48.00 in the primary spot when the coding sequence or non-surgical wound you are coding as primary does not fall into the wound primary clinical grouping.
Don’ts for proper use
The key to coding wound care accurately is knowing when your primary code does and does not fall into the primary wound clinical group.
Do not assign Z48.- codes — Z48.00 or Z48.01 — when the code that would otherwise be primary already groups to the wound care group under PDGM per the 2020 HH PPS Final Rule.
For example, do not assign Z48.00 when the focus of care — or primary diagnosis — is an L89.- code for pressure ulcer or L97.- code for non-pressure ulcer.
If the episode is grouping to wounds, then there is no purpose in assigning an additional, excessive Z code as primary. You may assign it as a secondary if you feel it is warranted, but keep in mind that the POC must still stand for itself.
Additionally, you should never use the Z48.- series for injuries or trauma.