Home Health Coding and OASIS Expert

Do you know which ulcers require two codes to report?

Brushing up on ulcer coding guidelines and details is the first step to coding these wounds correctly. The next step is to see how you fare when putting your knowledge to the test. Try your hand at coding these ICD-10 scenarios from Judy Adams, RN, BSN, HCS-D, HCS-O, AHIMA Approved ICD-10-CM Trainer with Adams Home Care Consulting in Asheville, N.C.

Scenario 1: Your 78-year-old cachectic female patient was admitted to home care for a shallow ulcer on her right heel, a full thickness loss on her right and left buttock and a shallow ulceration on her left ankle with presence of bone all noted to be due to pressure. How would you code for this patient in ICD-10?

Scenario 1 answer: Code for this patient as follows, Adams said:

• M1020a: L89.524 (Pressure ulcer of left ankle, stage 4); 

• M1022b: L89.313 (Pressure ulcer of right buttock, stage 3); 

• M1022c: L89.323 (Pressure ulcer of left buttock, stage 3); 

• M1022d: L89.612 (Pressure ulcer right heel, stage 2); 

• M1022e: R64 (Cachexia); and 

• M1022f: Z48.00 (Encounter for changing or removal of nonsurgical wound dressing).

The pressure ulcer category in ICD-10 doesn’t include codes for bilateral pressure ulcers, so you’ll need to list a code for each side to describe the ulcers on both sides of her buttocks, Adams says.

Tip: With ICD-10 pressure ulcer codes, the fifth character indicates laterality and the sixth character indicates the stage.

Following the pressure ulcer codes for this patient, you should report your patient’s cachexia. Code R64 is a symptom code. You’ll find a note under R64 in the Tabular List asking you to code first the underlying condition, if known. However, the medical record in this situation did not provide this information, so you can’t code for it.

You can add Z48.00 as an additional code as long as there are no complications such as infection, lack of healing, or other complication associated with your patient’s pressure ulcers.

Scenario 2: Your 82-year-old male patient has ulcerated varicose veins on his right shin and left calf limited to skin breakdown. He requires daily dressing changes with lotion applied daily to the non-ulcerated portions of the legs due to stasis dermatitis. He also has cardiac arrhythmia. How would you code for this patient in ICD-10?

Scenario 2 answer: Code for this patient as follows, Adams said during the recent Eli-sponsored audioconference “Unravel Wound Care Coding in ICD-10:”

• M1020a: I83.218 (Varicose veins of right lower extremity with both ulcer of other part of lower leg and inflammation);

• M1022b: L97.811 (Non-pressure chronic ulcer of other part of right lower leg limited to skin breakdown of skin);

• M1022c: I83.222 (Varicose veins of left lower extremity with both ulcer of calf and inflammation);

• M1022d: L97.221 (Non-pressure chronic ulcer of left calf limited to breakdown of skin);

• M1022e: Z48.00 (Encounter for change or removal of nonsurgical wound dressing); and

• M1022f: I49.9 (Cardiac arrhythmia, unspecified).

All non-pressure chronic ulcers require an additional code from the L97- category in ICD-10 to identify the severity. So you’ll need to list two codes to describe each of your patient’s ulcers. The severity is based on depth of the ulcer along with the location and side of the body, Adams said.

Severity options are:

• Limited to breakdown of skin

• With fat layer exposed

• With necrosis of muscle

• With necrosis of bone

You’ll also need to include codes for the dressing changes and your patient’s cardiac arrhythmia.

Scenario 3: Your patient was admitted with a stage 3 decubitus ulcer of coccyx. At recert, the patient’s decubitus ulcer has continued to heal and has now filled with healthy granulation tissue nearly to the top of the wound. The patient has developed wounds on the left shin, left midfoot, and left heel involving skin breakdown only. The physician indicates that these are diabetic ulcers. The diabetic ulcers are the primary focus of care. How would you code for this patient in ICD-10?

Scenario 3 answer: Code for this patient as follows, Adams said:

• M1020a: E11.622 (Type 2 diabetes mellitus with other skin ulcer);

• M1022b: L97.821 (Non-pressure chronic ulcer of other part left lower leg limited to breakdown of skin);

• M1022c: E11.621 (Type 2 diabetes mellitus with foot ulcer);

• M1022d: L97.421 (Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin); and

• M1022e: L89.153 (Pressure ulcer of sacral region, stage 3).

Diabetes has five distinct categories of combination codes in ICD-10. Look to category E11.6- for Type 2 or diabetes, NOS with skin complications. You’ll need to report two codes from this category for your patient because one ulcer is on the shin so you’ll code for it “with other skin ulcer” (E11.622), while you’ll code for diabetes, NOS with ulcers of the midfoot with E11.621 (… with foot ulcer).

Take note: Both of these E11.62- codes require an additional code to identify the sites of these non-pressure ulcers. Left midfoot and heel are both covered with L97.421, and you’ll report other part of left lower leg with L97.821. The stage 3 pressure ulcer code, on the other hand, is a combination code for both the location and the stage of the pressure ulcer.