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.
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.
Click image below to see larger detail.
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
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:
- Varicose veins of the right lower extremity with both ulcer and inflammation on the calf, I83.212
- Severity: nonpressure chronic ulcer of right lower calf with fat layer exposed, L97.222
Diabetic or Neurotropic Ulcers
Diabetic or neurotropic ulcers are foot ulcers that are open sores or wounds on the feet that do not completely heal or return after initial healing. These ulcers typically occur as a result of advancing diabetes and affect weight-bearing points on the bottom of the foot.
The provider must document whether the patient has type 1 or type 2 diabetes and indicate the laterality of the ulcer, as well as the location.
Figure 3 shows an example of the documentation and coding for a neurotrophic ulcer:
- Type 2 diabetes mellitus with chronic right foot ulcer on the midfoot and heel with breakdown of the skin
- Type 2 diabetes mellitus with right foot ulcer, E11.621
- Nonpressure, chronic ulcer right midfoot and heel with breakdown of the skin, L97.411
Click image below to see larger detail.
Patients at risk for neurotrophic ulcers include those with a history of numbness, paresthesia, or loss of sensation in the foot.
Ischemic or Arterial Ulcers
Ischemic or arterial ulcers are due to poor circulation. The typical primary diagnosis is peripheral arterial disease, commonly referred to as PAD. The occurrence of an arterial ulcer is a risk factor of PAD.
The provider must document atherosclerosis of native arteries, including laterality, and indicate the location and severity of the ulcer.
An arterial ulcer can be coded as:
- Atherosclerosis of native arteries of left ankle with ulceration, I70.243
- Nonpressure, chronic ulcer of left ankle with necrosis of muscle, L97.303
Patients at risk for arterial ulcers include those with a history of smoking and intermittent claudication.
Typical descriptors for the skin status include the following:
- Shear – stretching of the tissues when a patient's body is moved up in bed
- Slough – dead tissue that separates from living tissue, often yellow in color
- Eschar – black tissue that often forms a hard shell over an ulcer
Patients and caregivers can use a variety of preventive measures to avoid ulcers. Still, ulcers occur in many patients. While physicians and their clinical teams can assist patients in developing the best strategy to meet their needs, medical coders can ensure patients' records are being coded appropriately during the future transition to ICD-10.
Valerie Fernandez is an AHIMA certified trainer for ICD-10 CM and ICD-10 PCS and participates in its Ambassador program for ICD-10. Currently, she is the ICD-10 quality assurance manager for Special Surgery in New York. She also holds a CPC and CPC-H from the American Academy of Professional Coders (AAPC).