Home Health ICD-9/ICD-10 Alert

List only one staging code for ulcers of the same stage.

With the 2009 ICD-9 update effective Oct. 1, pressure ulcer coding has become more detailed and more involved. Are you ready for the challenge?

As a home health coder, you likely report lots of patients with pressure ulcers, so you'll need to frequently use the new additional codes 707.20-707.25 (Pressure ulcer stages) to show the stage of pressure ulcers.

To make sure you're using these new pressure ulcer staging codes correctly, read Chapter 12 in the new Official Coding Guidelines effective Oct. 1 very carefully, advises Judy Adams, RN, BSN, HCS-D, with LarsonAllen in Charlotte, N.C. Especially important points include the following:

1. There's a difference between "stage unspecified" and "unstageable." Code 707.20 (Pressure ulcer, unspecified stage) is not the same as 707.25 (Pressure ulcer, unstageable), Adams says. You should use 707.20 only when there is no documentation in the record of the stage of the pressure ulcer.

Good news: You don't have to rely on the physician to provide the pressure ulcer stage, but someone should query the physician if there is no detailed documentation present. The coding guidelines indicate that any clinician can determine the stage based upon guidance available from the Wound, Ostomy, and Continence Nurses Society (WOCN) or the National Pressure Ulcer Advisory Panel (NPUAP), Adams says.

2. No stage or unstageable means no points. The biggest challenge in establishing the stage of a healing pressure ulcer is that you can't reverse stage a pressure ulcer, Adams says. Say your agency receives a referral for a patient who has a healing pressure ulcer and there is no documentation in the record. In this case, the clinician can't just rely on assessment skills but must try to find out what stage that pressure ulcer was at its worst stage.

The alternative is to use 707.20 to indicate stage unspecified, but this will result in lost revenue opportunities for your agency. Medicare PPS gives points for both case mix and nonroutine supplies (NRS) based on the stage of the most problematic observable pressure ulcer.

Another challenge for home health occurs when you must stage a pressure ulcer as unstageable (707.25) because it is covered by eschar, a skin or muscle graft, or is a deep tissue injury not due to trauma, Adams says.

Tricky: OASIS guidance doesn't always coincide with coding guidance, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas. Remember that the Centers for Medicare & Medicaid Services says to use OASIS guidance for OASIS and coding guidance to code.

Coding vs. OASIS: An ulcer covered by eschar loses the opportunity for HHRG points but still earns NRS points, Selman-Holman points out. A pressure ulcer covered by a skin graft is still documented on OASIS according to stage but should be coded as unstageable (707.25). A pressure ulcer treated with a muscle graft is no longer a pressure ulcer by OASIS standards but is coded as unstageable (707.25).

Coding example: Your patient has bilateral pressure ulcers of the buttocks. One is a stage 3 and the other a stage 2. He also has a stage 4 pressure ulcer of the sacrum. Code for this patient as follows, Adams says:

• M0230a: 707.03 (Pressure ulcer; sacrum);

• M0240b: 707.24 (Pressure ulcer stage IV);

• M0240c: 707.05 (Pressure ulcer; buttock);

• M0240d: 707.23 (Pressure ulcer stage III); and

• M0240e: 707.22 (Pressure ulcer stage II).

Coding for this patient uses five of the six reportable diagnosis spots on the OASIS, Adams points out. Clinicians will have to think carefully about sequencing these situations, especially for patients who may have other co-morbidities.

Another example: Your patient was referred to home health with a stage 3 pressure ulcer of the coccyx and the hip and a stage 2 pressure ulcer on the ear.

• M0230a: 707.05 (Pressure ulcer; buttock);

• M0240b: 707.04 (Pressure ulcer; hip);

• M0240c: 707.23 (Pressure ulcer stage III);

• M0240d: 707.09 (Pressure ulcer; other site); and

• M0240e: 707.22 (Pressure ulcer stage II).

This situation is coded slightly differently than the first. You'll list a code for each of the three locations, but only two stage codes, Adams says. This is because the ulcers in two locations are the same stage, and coding rules prohibit repeating the same code more than once for a claim.

Avoid this mistake: Use the 707.2x codes only when reporting pressure ulcers, cautions Trish Twombly, RN, BSN, HCS-D, CHCE, director of coding with Foundation Management Services in Denton, Texas. Don't be tempted to use a code from the 707.20-707.25 range to report staging for arterial, venous, or diabetic ulcers.