Internal Medicine Coding Alert

Published on Fri Nov 27, 2009 PDF

Question: A 75-year-old female established Medicare patient reports to the practice for inspection of sores on her back. The nonphysician practitioner (NPP) diagnoses a stage I pressure ulcer on her lower back. The NPP refers the patient to a dermatologist for treatment of the ulcer. How should I report this diagnosis?

Indiana Subscriber

Answer: You should submit a pair of codes; one to represent the stage of the pressure ulcer, and another for the ulcer itself.

On the claim, report the following:

• 707.03 (Pressure ulcer; lower back) to represent the pressure ulcer and 707.21 (Pressure ulcer stage I) to represent the pressure ulcer's stage.

Explanation: Use the "stage" codes to describe the status of the patient's wound -- but code the ulcer location first using 707.00-707.09.

No incident-to here: Since there was no mention of an established plan of care in place or physician supervision for the encounter, code any services from the visit under the NPP's National Provider Identifier (NPI).

-- Answers to You Be the Coder and Reader Questions were reviewed by Bruce Rappoport, MD, CPC, CHCC, a board-certified internist and medical director of Broward Health's Best Choice Plus and Total Claims Administration in Fort Lauderdale, Fla.