Home Health Coding and OASIS Expert

Don’t fall into this unspecified trap.

Coding accurately for pressure ulcers can garner your agency case mix points and additional reimbursement. Take a few moments to give your current coding practices a review and get a preview of the way you’ll code for these wounds in ICD-10.

List Two Codes in ICD-9

ICD-9 requires two codes for a pressure ulcer, says Judy Adams, RN, BSN, HCS-D, HCS-O, with Adams Home Care Consulting in Asheville, N.C. The first code indicates the location of the ulcer and the second code indicates the stage of the ulcer, she says.

For example: 707.05 (Pressure ulcer; buttock) and 707.23 (Pressure ulcer, stage III).

Add Laterality in ICD-10

One of the greatest drawbacks to coding for pressure ulcers in ICD-9 is the inability to show laterality, Adams says. Fortunately, ICD-10 improves on this.

“ICD-10 makes coding pressure ulcers much easier since there are combination codes available that include the location as well as the stage and my favorite part, laterality,” Adams says.

For example: L89.313 (Pressure ulcer of right buttock, stage 3).

Strange: “I was really surprised that ICD-10 did not offer a bilateral option for pressure ulcer, especially for hips and buttocks because those are often seen,” Adams says. “As it stands, the coder will have to add a separate code for each ulcer that has a different laterality.”

The ICD-10 coding manual also adds more detail in the codes themselves. “I particularly like that the code definition in ICD-10 spells out the definition of the stages that I think will further help coders select the correct stage,” Adams points out.

For example: Here’s what the entry for a stage 3 pressure ulcer on the right elbow looks like in the ICD-10 manual:

L89.013 Pressure ulcer of right elbow, stage 3

Healing pressure ulcer of right elbow, stage 3
Pressure ulcer with full thickness skin loss involving
damage or necrosis of subcutaneous tissue,
right elbow

Know How to Handle Unstageable and Unspecified 

Both ICD-9 and ICD-10 offer codes for Unstageable pressure ulcers, Adams says. “Unstageable continues to be defined as an ulcer that is covered with slough or eschar to the degree that the clinician cannot see the base of the ulcer to determine the structures involved,” she says.

Both code sets also provide codes for unspecified pressure ulcers. But “I really hope coders have learned by now not to code unspecified pressure ulcer in either ICD-9 or ICD-10,” Adams says.

Why? While the physician must confirm that there is a pressure ulcer in both ICD-9 and ICD-10 before you can code for it, there is no requirement for the physician to identify the stage, Adams says. Because the clinician can determine the stage of each pressure ulcer, using an unspecified code for these wounds is a poor choice.

Mistake: Clinicians who don’t do thorough skin assessments to identify the presence of pressure ulcers, or who don’t look at the ulcers to determine stage are missing out, Adams says. This hurts in both accurate diagnosis coding and OASIS scoring. And it’s “not only poor clinical practice, but throws away case mix points and reimbursement,” she says.

Reminder: Not determining the correct stage means that you may miss out on providing appropriate care. Case mix points are based on answers to the M1308 and M1324 OASIS items, not the diagnosis codes you report.

ICD-10 difference: The directions for how to code for pressure ulcers when gangrene is present will change when you move from ICD-9 to ICD-10, Adams points out. In ICD-9, you’ll add an additional code (785.4) for gangrene after coding the location and stage of the pressure ulcer. But in ICD-10, the coding manual instructs you to code first any associated gangrene with I96 (Gangrene, not elsewhere classified).

Consider this Coding Scenario

Now that you know how your pressure ulcer coding will differ in ICD-10, why not put your knowledge to the test? But first, make certain your ICD-9 coding skills meet the mark with this coding scenario from Adams.

Your new patient is a 78 year-old cachectic female. She was admitted to home health for a shallow ulcer on her right heel (Stage 2), a full thickness loss on her right and left buttock (stage 3) and a shallow ulceration on her left ankle with presence of bone (stage 4).

In ICD-9, you would code for this patient as follows:

• M1020a: 707.06 (Pressure ulcer; ankle);
• M1022b: 707.24 (Pressure ulcer; Stage IV);
• M1022c: 707.05 (Pressure ulcer; buttock);
• M1022d: 707.23 (Pressure ulcer; Stage III);
• M1022e: 707.07 (Pressure ulcer; heel);
• M1022f: 707.22 (Pressure ulcer; Stage II); and
• Other diagnoses: 799.4 (Cachexia)
                                    V58.30 (Encounter for change or removal of nonsurgical wound dressing).

In ICD-10, you would code for this same patient as:

• M1021a: L89.524 (Pressure ulcer of left ankle, stage 4);
• M1023b: L89.313 (Pressure ulcer of right buttock, stage 3);
• M2023c: L89.323 (Pressure ulcer of left buttock; stage 3);
• M1023d: L89.612 (Pressure ulcer of right heel; stage 2);
• M2023e: R64 (Cachexia); and
• M1023f: Z48.00 (Encounter for change or removal of non-surgical wound dressing).