Health data standards and systems

In reference to VICC query #2508 Wound ooze, the response that states 'wound observation/monitoring and dressing management are routine post-operative care... you would need documentation of care or management of the wound that is beyond routine care'.
Can you please provide some advice on whether or not wound ooze should be coded in the following examples:

1. Nursing notes 9/7 0610: POP L) leg – oozing on plaster marked.
Nursing notes 9/7 1440: L leg plaster insitu, has old ooze, elevated on pillow LMO notified on 7232 to review patient regarding old ooze and ?D/C.
Ortho Res 9/7 2130: “ATRP re slight ooze in plaster. S/B Registrar (ortho) patient okay for discharge.”

2. Nursing notes: Moderate ooze from graft site. Reinforced. No more ooze.

3. Nursing notes 9/12 1750: L) groin Dx – slightly oozing and marked. Small further oozing. Nil further oozing after 2nd time marking.
Nursing notes 10/12 0345: Dx to L) groin has old ooze – marked @ 2200.

4. Nursing notes: For change of dressing as wound is oozing.

Search Details:
VICC Query #2508 Wound Ooze

VICC referred this query to ACCD who provided the following advice published in the December 2014 Coding Rules:

Postoperative wound ooze may refer to:
- Serous exudate – drainage of a clear, thin, watery fluid from a surgical wound. This type of wound ooze is a normal and expected part of the healing process
- Haemoserous (serosanguinous) exudate – drainage of a thin, watery, pink coloured fluid composed of blood and serum. This type of wound ooze is also a normal and expected part of the healing process
- Sanguinous exudate or haemorrhage – indicates a trauma to blood vessels
- Purulent (pussy) exudate – a yellow, grey or green odiferous discharge – indicates infection.

While small amounts of serous or serosanguinous exudate from a postprocedural wound is considered normal, excessive or increasing discharge may indicate a postprocedural complication.

The ACCD agrees that wound observation/monitoring and dressing management are routine postprocedural care and that wound ooze should only be coded when there is documentation of care or management of the wound that is beyond routine care.

Evidence that wound ooze has met the criteria for code assignment in ACS 0002 Additional diagnoses includes:
- Consultation/treatment by a clinician, including a wound specialist or stoma therapist (if this is outside of routine wound management in your facility)
- Application of vacuum dressing or other dressing/device outside of the routine type of dressing material (for example, stoma bags may be used in place of conventional dressings where there is excessive discharge of exudate)
- Unexpected/unplanned return to theatre for wound exploration/insertion of a drain.

The above list should not be considered exhaustive and each case must be considered on its own merits. Where there is uncertainty as to whether wound ooze is in excess of the normal healing process or is indicative of haemorrhage or infection (and these terms are not documented), confirmation should be sought from the treating clinician.

When the above guidelines have been followed and criteria have been met, assign the following codes for wound ooze NOS:

T81.8 Other complications of procedures, not elsewhere classified
Y83-Y84 Surgical and other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure
Y92.22 (Place of occurrence) Health service area

Assign codes for postoperative haemorrhage or infection by following the guidelines in ACS 1904 Procedural complications. [end of ACCD response]

In addition to the ACCD response, VICC has developed the following additional instructions to clarify what constitutes routine care and beyond routine care. This advice must be followed for documentation of an intervention for wound ooze and is effective for separations on or after 1 April 2015.

1. Routine care – Wound ooze must not be coded for the following interventions:
- Dressings
- - scheduled changes of existing dressing e.g. third or fourth daily
- - non-scheduled changes of existing dressing
- - reinforcing of existing dressing
- - change of dressing from one type to another - see point 2 below for exclusion
- icing
- marking
- cleaning/cleansing
- wound swab
- elevation
- pressure

Note: The types of care detailed above cannot be queried with clinicians to gain advice that these are beyond routine care.

2. Beyond routine care – Wound ooze should only be coded when there is consultation with a clinician resulting in a change of patient management, for example:
- commencement of antibiotics
- delayed discharge
- debridement of wound
- theatre management
- change of dressing to negative pressure wound therapy (vacuum) or stoma bag

Wound ooze requiring consultation with a clinician resulting in any of the interventions in point 1 must not be coded.