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The Proper Documentation of Wound Dehiscence Under ICD-10

Any procedure that requires the creation of a cut or opening in the skin can result to a complication called wound dehiscence. This occurs when the surgical incision reopens after closure, posing a threat to the healing of the wound and the individual’s overall health. According to recent statistics, 45% of wound dehiscence cases lead to mortality.

The causative factors for wound dehiscence are vast and various. As medical practitioners, it’s important to properly document these specifics in order to provide other professionals in the healthcare setting an accurate clinical picture of each individual case. Proper documentation under ICD-10-CM guidelines is also highly important, as this will assist in assessing the patient’s eligibility for medical insurance coverage.

For this reason, understanding the specifics of wound dehiscence as well as its coding under the International Classification of Diseases should be a primary priority for any health care worker.

How Does Wound Dehiscence Happen?

As much as possible, doctors will guarantee proper wound closure during an operation as this is an imperative aspect of proper healing. However, certain cases may make wound dehiscence a highly likely probability. There are also instances when the patients themselves are at fault. Overestimating the integrity of surgical stitching and staples is a common reality, causing dehiscence out of failure to follow post-operative instructions.

The most common reasons for the occurrence of wound dehiscence include:

  • Overexertion through strenuous physical activity or exercise
  • Excessive laughter
  • Coughing and sneezing
  • Bearing down during bowel movement
  • Lifting heavy objects
  • Chronic disease like diabetes and AIDS
  • Poor skin integrity
  • Physical manipulation of the surgical site
  • Poor stitching or closure
  • Chemotherapy and radiation

Classifications of Wound Dehiscence Under ICD-10-CM

The ICD-10-CM is an international set of diagnostic guidelines used by medical professionals and health insurance companies to properly classify and categorize different medical conditions. The ICD provides practitioners a universal template that all of those involved in the provision of medical care can understand. This helps unify knowledge and also prevents miscommunication that could result to any errors throughout the medical care process.

Wound dehiscence under the ICD-10-CM is coded T81.3 which exclusively pertains to disruption of a wound not elsewhere classified. The purpose of this distinction is to rule out other potential wound-related complications that are categorized elsewhere in the ICD-10-CM.

To give you a better understanding of when and where you can use the T81.3 code for wound dehiscence, the specific case being assessed must not meet the following instances or criteria:

  • Mechanical breakdown of permanent sutures (T85.612)
  • Displacement of permanent sutures (T85.622)
  • Disruption of Cesarean delivery wound (O90.0)
  • Disruption of perineal obstetric wound (O90.1)
  • Mechanical complication of permanent sutures not elsewhere classified (T85.692)
  • Dehiscence of amputation stump (T87.81)

Inclusion terms that can be classified under the code T81.3 are:

  • Disruption of any suture materials or other closure methods
  • Dehiscence of operation wound not otherwise specified
  • Disruption of operation wound not otherwise specified
  • Disruption or dehiscence of closure of cornea
  • Disruption or dehiscence of closure of mucosa
  • Disruption or dehiscence of closure of skin and subcutaneous tissue
  • Full-thickness skin disruption or dehiscence
  • Superficial disruption or dehiscence of operation wound
  • Deep disruption or dehiscence of operation wound not otherwise specified
  • Disruption or dehiscence of closure of internal organ or other internal tissue
  • Disruption or dehiscence of closure of muscle or muscle flap
  • Disruption or dehiscence of closure of ribs or rib cage
  • Disruption or dehiscence of closure of skull or craniotomy
  • Disruption or dehiscence of closure of sternum or sternotomy
  • Disruption or dehiscence of closure of tendon or ligament
  • Disruption or dehiscence of closure of superficial or muscular fascia

Is T81.3 a Billable ICD-10-CM Code?

The code T81.3 is NOT a billable code under the ICD-10-CM because it lacks a 7th character. Based on ICD-10-CM guidelines, codes need to have at least 7 characters in order to be considered billable codes, thus anything shorter may not qualify for reimbursement.

The reason for this is because the code T81.3 doesn’t offer maximum specificity, leaving some room for guesswork if you’re a medical practitioner or a health insurance provider. Without sufficient information on the actual case, it may be impossible for insurance companies to provide an exact value for reimbursement. With that, it’s important to apply a 7th character to the code in order to provide maximum specificity.

Billable Codes for Wound Dehiscence

To reduce the financial burden on patients, doctors and health care professionals need to fulfil certain parameters. With the ICD-10-CM, that includes coming up with a 7 digit code which is considered the most specific possible diagnosis.

Because the code for a wound dehiscence only consists of 5 digits, there are specifiers you can use to make the diagnosis more precise. These specifiers can either designate when the dehiscence occurred relative to treatment, or the nature and location of the dehiscence.

Specifier

Code Placement

Interpretation

0

T83.10

Unspecified

1

T81.31

Internal wound

2

T81.32

External wound

3

T81.33

Trauma

A

T81.3XXA

Initial encounter

D

T81.3XXD

Subsequent encounter

S

T81.3XXS

Sequela

 

The numerical specifiers ranging from 0-3 indicate the location of the wound involved. These numbers take the fifth place in the code. However, because the code for wound dehiscence requires seven characters to be considered billable, healthcare providers need to indicate another specifier.

In the case of wound dehiscence, there are only two possible specifiers which can be added to the original 4 digit code. To reach the minimum required seven character limit, an “X” should be added as a placeholder for any missing characters in the code. So for a complete billable code, the sixth space should be filled in with an X.

The seventh specifier can either be A, D, or S. This tells readers the specific time at which the wound dehiscence occurred.

A is used to identify an initial encounter. This pertains to wound dehiscence that occurs during the active phase of treatment. Most often, this type of complication occurs as a result of an individual’s physical capacity for healing. Those who have pre-existing medical conditions are more likely to experience dehiscence early on as their bodies are ill equipped to properly heal the surgical wound.

D pertains to a subsequent encounter. Any wound dehiscence that occurs after the active phase of treatment can be classified with the D specifier. So, patients that experience this type of complication are often discharged from the hospital. Wound care is performed at home after the provision of instructions from a qualified medical practitioner. Poor follow-through is often assumed to be the primary cause for a subsequent encounter.

S stands for sequela, and refers to wound dehiscence that occurs as a direct result of an injury. For instance, scar formation is considered a common sequela of wound healing.

Practical Application

For the sake of example, let’s say a patient seeks medical attention after experiencing wound dehiscence. The patient claims to have been moving boxes around his home when he felt a sharp pain in his abdomen along the site of a recent surgical incision for an appendectomy.

Upon inspection, the physician in charge sees that the closure had reopened. The course of treatment for that specific case entailed cleaning, debridement, and reclosure of the suture.

In this example, coders will use the ICD-10-CM code T81.31XA. The initial T81.3 indicates wound dehiscence. The specifier 1 pertains to an internal wound. The sixth character X is used as a placeholder. And the seventh character A indicates an initial encounter.

Treating Wound Dehiscence

These codes from the ICD-10-CM also help guide health care providers as to the proper treatment methods for specific conditions. In the case of wound dehiscence, there are several steps doctors need to take in order to guarantee proper and efficient healing of the reopened suture.

Before a doctor jumps in to treat an open suture, it’s first important to determine how deep the wound has dehisced. Partial wound dehiscence pertains to cases wherein only the superficial layers of the wound have reopened, thus leaving some depth of the suture intact.

Complete wound dehiscence on the other hand, is used to describe cases where all the layers of the wound thickness have separated and reopened. This type of dehiscence is most common in abdominal sutures, and sometimes even allows internal structures to move out towards the open wound.

Once the doctor assesses the case, debridement is the first step to addressing the situation. At this phase, specialists work to remove dead or infected tissues and clean away debris that the patient may have accumulated around the wound.

The site is then flushed out with a medicated fluid to sterilize the area so that it heals properly once closed. After this, doctors will stitch or staple the wound, and then they commonly prescribe antibiotics to be taken over a period of two weeks.

Antibiotics are given even in the absence of an infection. This is simply because wound dehiscence cases are often prone to bacterial infection because of the delicate and exposed nature of the wound tissues.

Conclusion

As one of the most common post-surgical complications, wound dehiscence is something anyone in the health care industry should fully comprehend. This includes a detailed understanding of its documentation under the guidance of the ICD-10-CM.

By keeping yourself updated on the latest changes relating to the ICD, you can keep up with other healthcare professionals and help establish a strong interdisciplinary approach that ultimately results to optimal medical care and service provision for all.

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