Documenting and Coding Superficial Skin Tears
According to OASIS guidelines, the care of skin tears is typically not covered by Medicare because the wound care is simple.
There are certain circumstances where the skin tear may be coded as an open wound instead of superficial injury.
Based on Payne-Martin Classification for Skin Tears
CATEGORY 1: Skin tears without loss of tissue are subdivided into:
Linear type, in which the epidermis and dermis are pulled in one layer from the supporting structure.
Flat type, where the epidermis and dermis are separated, but the epidermis flap covers the dermis to within 1mm of the wound margins.
Category 1a: A skin tear where the edges can be realigned to the normal anatomical position
(without undue stretching) and the skin or flap color is not pale, dusky or darkened.
Category 1b: A skin tear where the edges can be realigned to the normal anatomical position
(without undue stretching) and the skin or flap color is pale, dusky or darkened.
Category 1 should be coded as superficial wounds.
CATEGORY 2: Scant loss of tissue, maximum 25% moderate to large loss of tissue, more than 25% of the entire flap lost during the trauma.
Category 2a: A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap color is not pale, dusky or darkened.
Category 2b: A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap color is pale, dusky or darkened.
Category 2 may be coded as traumatic open wounds if complicated by infection or an underlying disease such as diabetes.
CATEGORY 3: This type of skin tear involves the entire loss of tissue. It can be caused by the initial trauma, or necrotization of the skin flap.
Category 3 should be coded traumatic open wounds.
*Documentation must support the need for skilled wound care*
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