Home Health Coding and OASIS Expert

Question: Our new patient has a stage 3 pressure ulcer on her right buttock, a stage 4 pressure ulcer on her right shoulder blade, and a suspected deep tissue injury (DTI) on her right heel. She also has diagnoses of type 2 diabetes and failure to thrive. We will be providing dressing changes on her stage 3 and stage 4 pressure ulcers and pressure relief for the suspected DTI with no dressings. How should we code for this patient?

 Answer: Code for this patient as follows, 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.

• M1021a: L89.114 (Pressure ulcer of right upper back, stage 4);
  
• M1023b: L89.313 (Pressure ulcer of right buttock, stage 3);
  
• M1023c: E11.9 (Type 2 diabetes mellitus without complications);
  
• M1023d: R62.7 (Adult failure to thrive);
  
• M1023e: L89.610 (Pressure ulcer of right heel, unstageable); and
  
• M1023f: .Z48.00 (Encounter for change or removal of nonsurgical wound dressing).
  

List your patient’s stage 4 pressure ulcer in M1021. Care for her wounds is your primary focus of care, and the stage 4 pressure ulcer is the most serious. Follow this with L89.313 to report her stage 3 pressure ulcer. Note that it is not always the highest stage that requires the most care. For example, the stage IV may be granulating well but the stage III, because of its location, becomes regularly contaminated by stool. In that case the stage III could very well be sequenced as primary, Selman-Holman adds.

Next, list the code for her diabetes; E11.9. This condition will impact the healing of her wounds and the care you provide.

Note: Don’t assume that just because your patient has ulcers and diabetes, that they are diabetic ulcers. The medical record reports that this patient has pressure ulcers, so you should code for them as such.

Following the diabetes code, list R62.7 to indicate that your patient has adult failure to thrive. This condition will also impact the time and care involved in healing her pressure ulcers.

List L89.610 to indicate that your patient also has a suspected DTI. This code for unstageable pressure ulcers is also the appropriate code to report for DTI.

Finally, include Z48.00 to indicate that you will be providing dressing changes for this patient.