Home Health ICD-9/ICD-10 Alert

Question: Our new patient fell at home and he remained on the floor for three days until his daughter found him. He has a large purplish bruise over his sacral area. Two days later he developed a large necrotic area over the sacrum and it is documented as a suspected deep tissue injury (DTI). We have orders to provide skilled nursing to assess integumentary status. How should we code for him?

Connecticut Subscriber

Answer: Code for this patient as follows, says Joan L. Usher, BS, RHIA, COS-C, ACE, with JLU Health Record Systems in Pembroke, Mass.:

• M1020: 707.03 (Pressure ulcer; lower back);
• M1022b: 707.25 (Pressure ulcer; unstageable); and
• M1022c: V15.88 (At risk for falling).

A DTI is a purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear, Usher says. Code for these wounds as unstageable pressure ulcers, and be sure they are also reported accurately in the relevant OASIS items.

For M1306 — Does this patient have at least one Unhealed Pressure Ulcer at Stage II or Higher or designated as unstageable the correct response for this patient is “Yes.”

In M1308 — Current number of unhealed [non-epithelialized] pressure ulcers, you’ll count this wound in d.3 — Unstageable: Suspected deep tissue injury in evolution.

Your M1320 — Status of most problematic pressure ulcer is “Non-healing” because DTIs do not granulate and are not covered with new epithelial tissue.