Home Health Coding and OASIS Expert

The jury’s still out on ulcer severity selection.

Now that you’re learning by doing with ICD-10, you’ve likely had some questions about how to use the new code set. From coding for wounds to general coding instructions read on for expert answers.

Add-ons optional:  Many home health coders have had questions about ICD-10 instruction codes, says Judy Adams, RN, BSN, HCS-D, HCS-O, AHIMA Approved ICD-10-CM Trainer with Adams Home Care Consulting in Asheville, N.C. Some coders are seeing the “add an additional code” instruction, but when the patient doesn’t have one of the conditions listed or something similar, they become confused, she says. “You cannot code a condition a patient does not have, and unless the note is at an etiology/manifestation code situation, the note serves as a reminder rather than a mandate.”

Non-healing wound conundrum: Another area that’s been a head-scratcher for home health coders in particular is how to code for a non-healing wound. There is no specific code for this situation in ICD-10 and the best guidance points to T81.89 (Other complications of procedures not elsewhere classified).

Unfortunately, figuring out how to find T81.89 in the alphabetic index is no easy task. “I searched the PDF of the alphabetic index on the Centers for Disease Control website,” says Lisa Selman-Holman, JD, BSN, RN, COS-C, HCS-D, HCS-O, AHIMA Approved ICD-10-CM Trainer/Ambassador of Selman-Holman & Associates, LLC, CoDR — Coding Done Right and Code Pro University in Denton, Texas. “The terms to find that code really do not relate to anything you would think of to reference. My advice is to write the code on the inside cover of your manual,” she says.

Puzzling: “This code has a ‘use additional code to specify complication’ note,” Adams points out. “However, I have not been able to find another code that adds any clarification.” Hopefully, in the future, the cooperating parties will agree to add a code to ICD-10 to report a nonhealing or slow healing surgical wound, she says. “Apparently, only home health runs into this situation.”

Ulcer issues: Another big issue home health coders are facing centers around the definitions of severity for non-pressure ulcers. The sixth digits of codes for non-pressure ulcers designate the severity of the wound. Sixth character “1” indicates an ulcer limited to breakdown of the skin, while “2” describes an ulcer with an exposed fat layer.

However, the current definitions for more severe ulcers involving visible muscle and bone both include the presence of necrosis. That means that for non-pressure chronic ulcers with muscle necrosis, the correct sixth character is “3” and for non-pressure chronic ulcers with bone necrosis, the appropriate sixth character is “4.”

For example: You would code for a non-pressure chronic ulcer of the left thigh with necrosis of the muscle as L97.123, and if the same wound exhibited necrosis of the bone, you would choose L97.124.

But what sixth character should you choose when you can see muscle or bone in the wound but it is not necrotic?

“If the muscle or bone is not necrotic it would not be appropriate select 6th characters for muscle or bone necrosis,” Coding Clinic replied in response to a question about selecting ulcer severity codes, Selman-Homan says.

Pressure ulcer severity is one of the few diagnosis coding areas where clinicians have been given the authority to make a determination, but recent guidance from the Coding Clinic seems to indicate otherwise when it comes to non-pressure chronic ulcers. In this situation, Coding Clinic advised coders to review the record and contact the provider if he or she describes an ulcer in terms that are not found in the classification, Selman-Holman says. “If the ulcer is not further specified, it would be appropriate to report the 6th character for unspecified severity.”

Bottom line: “If necrosis is not present, agencies would have to code all deep non-pressure ulcers as unspecified which makes no sense for accurate data collection,” Adams said.

Lingering question: “We know we are not supposed to reverse stage pressure ulcers,” Selman-Holman points out. “But how do we code the severity of non-pressure ulcers when healing?”

Other issues: Overall, it seems “most errors are due to not using the correct code set based on date of service in home health,” Adams says.

So far, the transition seems to be going pretty smoothly, Adams says, “and there is good news on the horizon that future coding guidance will address home health and hospice issues as well as hospital and physician issues.”

Plus: “There is a workgroup of the major home care associations working with the CMS Coding Ombudsmen to resolve some of the issues unique to home health and hospice, which is really exciting,” Adams says.