# Non-Pressure Ulcer Severity Coding



## stogsmom3 (Nov 6, 2017)

I do wound care coding for the professional side.  I'm wondering how to code a non-pressure ulcer severity, when the provider documents tendon exposure, but doesn't state that the muscle is exposed with/without necrosis.  Also, often times they'll debride the tendon but not the muscle.  Would I code the 11042 or 11043 if debrided excisionally?

Thanks
Melissa


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## AlanPechacek (Nov 8, 2017)

I am certainly no Wound Care Specialist, but there are new and expanded severity codes for Non-pressure Chronic Ulcers for 2018, in particular in the 6th Characters.  The new 6th Character 5 is for "with muscle involvement *but* without evidence of muscle necrosis."  This does not address either Fascia or Tendon, both of which are essentially a part of the muscle.  The 6th Character 3 is for "with necrosis of muscle," which also doesn't address Fascia or Tendon.  Lastly, there is 6th Character 8 which is for "with *other* specified severity."  Since neither 3 or 5 includes Fascia and/or Tendon, then 8 may be the best option for this dilemma.
     As for the CPT codes you bring up, I would consider any debridement of necrotic tendon to be the equivalent of debridement of either or both muscle and fascia, i.e. 11043.
     I would like to see what others (the experts) say about this.

Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com


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## stogsmom3 (Nov 21, 2017)

Thank you for that information.  It confirms my thoughts as well.  But, I'm not an expert.


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