Code Ulcers Appropriately By Valerie Fernandez, MBA, CPC, CPC-H, AHIMA ICD-10 Trainer Even though the implementation of ICD-10 has been delayed for a year, it is important to consider how to appropriately code specific medical conditions. Ulcers represent one general diagnosis category that require specificity under ICD-10. We will start with the basics. Documentation requirements for ulcers include the following: indicating the type of ulcer and the location, laterality, and stage. The chart in Figure 1, which comes from the american medical Directors association Clinical Practice guidelines (amDa CPg), provides a summary of the distinguishing features of various types of ulcers, as well as the location where they often appear. PRESSURE ULCERS a pressure ulcer is an injury to the skin occurring when a patient sits too long or remains in the same position. When this happens, the cells and tissue in that area die, resulting in an open sore. In severe cases, the muscle, tendon, or bone may begin to show. Pressure ulcers occur on pressure points, such as the tailbone, buttocks, elbows, heels, and hips. There are four stages of pressure ulcers. The table in Figure 2 provides details on each stage. The physician must document the presence of a pressure ulcer. any associated gangrene is coded first, as I96. In ICD-10, there are 150 codes for pressure ulcers. listed below are several examples of ICD-10 codes for ulcers: • Pressure ulcer of right elbow: unstageable l89.010 • Pressure ulcer of right elbow: stage I l89.011 • Pressure ulcer of right elbow: stage 2 l89.012 • Pressure ulcer of right elbow: stage 3 l89.013 • Pressure ulcer of right elbow: stage 4 l89.014 Diagramed on page 38 (Figure 3) are the ICD-10 diagnosis code characteristics for a pressure ulcer of the right elbow, stage 1. ulCer TYPe PaTHOPHYsIOlOgY lOCaTION Diabetic . . . . . . . . . Peripheral neuropathy secondary to small or large vessel . . . . usually lower extremities (Neurotrophic) disease in chronic, uncontrolled diabetes Ischemic . . . . . . . . . reduction in blood flow to tissues caused by coronary . . . . . . . usually distal lower extremities (Arterial) artery disease, diabetes mellitus, hypertension, Tips of toes hyperlipidemia, peripheral arterial disease, or smoking Pressure . . . . . . . . . unrelieved pressure resulting in damage to skin or . . . . . . . . . . usually over bony prominences (e.g., buttocks, underlying tissue elbows, heels, ischium, medial and lateral malleolus, sacrum, trochanters) Venous Stasis . . . . Venous hypertension resulting from incompetence of . . . . . . . . usually lower leg region venous valves, postphlebitic syndrome, or venous insufficiency; tend to be irregularly shaped VENOUS STASIS ULCERS a venous stasis ulcer is a breakdown of skin caused by fluid buildup from poor vein function (i.e., venous insufficiency). risk factors include obesity, varicose veins, blood clots in the legs, and leg injury. Coding guidelines for venous stasis ulcers require that the provider must indicate the presence of varicose veins, laterality, inflammation, and the severity of the venous stasis ulcer. Documentation and coding include: ICD-10 Stage of Pressure Ulcer Description stage 1 . . . . . . . . . . . . . . . . skin is intact with redness stage 2 . . . . . . . . . . . . . . . . shallow, open ulcer with red wound bed stage 3 . . . . . . . . . . . . . . . . subcutaneous fat may be visible stage 4 . . . . . . . . . . . . . . . . Bone, tendon, or muscle is exposed unstageable . . . . . . . . . . . . ulcer is covered with slough or eschar THe jOurNal OF THe HealTHCare BIllINg aND maNagemeNT assOCIaTION 37 FIgURE 1 FIgURE 2
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